HospitalInspections.org

Based on document review and interview, it was determined that in 1 of 10 (Pt #1) clinical records reviewed, the Hospital failed to ensure the physicians' orders were followed as written.

Findings include:

1. The clinical record of Pt #1 was reviewed on 8/7/15. Pt #1 was a 66 year old female admitted on 6/10/15 with a diagnosis of spinal stenosis/kyphoscoliosis. Pt #1's clinical record contained a physician's order dated 6/15/15 at 8:07 PM to "avoid prolonged sitting (greater than 45 minutes." Nursing documentation dated 6/16/15 included that Pt #1 was in the chair from 2:58 PM to 5:24 (2 hours and 26 minutes).

2. On 8/7/15 at approximately 12:50 PM the Orthopedics Clinical Nurse Specialist (E #13) stated during an interview that the patient was up in the chair for 2 hours and not 45 minutes as ordered by the physician.

Based on observation, document review and interview, it was determined that for 3 of 3 staff observed with facial hair (E #7, 8, and 9) in the surgical department, the Hospital failed to ensure staff adherence to the OR dress code policy.

Findings include:

1. During observational tour of the surgical department on 8/5/15 between 9:00 AM and 10:30 AM, a clinical engineer (E #7) was in OR room 19 at 9:00 AM with his facial hair uncovered, Registered Nurse (E #8) was in the central core at 9:25 AM with his facial hair uncovered, and an environmental worker (E #9) was cleaning OR 16 at 10:30 AM with his facial hair uncovered.

2. The Hospital policy entitled, "Attire for Personnel - Operating Room/Post Anesthesia Care Unit/ Ambulatory Surgery Unit/Rush..." (approval Date 9/20/2012) required, "Policy: Dress Code Regulations...2. Personnel must cover head and facial hair completely when entering the semi-restricted and restricted areas."

3. The above findings were discussed with the Infection Preventionist (E #10) during an interview on 8/7/15 at approximately 10:15 AM. E #10 stated the staff should have been wearing beard covers.