HospitalInspections.org

Based on observation, interview and policy review the facility did not provide services in accordance with acceptable standards of practice and the facility's policy regarding operating room attire which potentially placed patients at risk.


Findings include:

Tour of the surgical suite on 7/22/15 revealed the following:

-Observation in Operating Room #3 at 9:45 AM revealed a right arteriovenous fistula creation in progress. Staff #22, RN and Staff #25, RN were observed with exposed hair. Staff #22 was observed with exposed earrings.

-Observation in Operating Room #9 at 11:20 AM revealed a lumbar fusion in progress. Staff #6 was observed wearing exposed earrings. Staff #7, Surgeon and Staff #8, Physician Assistant, were both observed to be wearing a face mask that did not cover their entire beard leaving the beard exposed on both sides of their faces.

-Observation in Operating Room #5 at 11:23 AM revealed a bilateral tubal ligation in progress. Staff #9, RN was observed wearing exposed earrings. Staff #10, Anesthesiologist, was observed wearing a skull cap type of head covering with exposed scalp hair.

-Observation in Operating Room #4 at 11:25 AM revealed a laparoscopic gastric bypass with colectomy in progress. Staff #11, RN was observed wearing exposed earrings and a ring.

-Observation in Operating Room #11 at 11:30 AM revealed a left total hip arthroplasty in progress. Staff #12 was observed wearing exposed earrings. Staff #23, sales representative, was observed wearing a skull cap type head covering with exposed scalp hair while entering room #11 and #12.

-Observation in Operating Room #12 at 11:33AM, revealed a right total knee arthroplasty in progress. Staff #13, Anesthesiologist, was observed wearing a skull cap type head covering with exposed hair. Staff #24, RN, was observed wearing a bouffant hair covering with exposed hair at the neck line.

-Observation in Operating Room #10 at 11:40 AM revealed a sigmoid colectomy in progress. Staff #15, RN was observed wearing exposed earrings.

Interview with Staff #3 on 7/22/15 verified the above findings.

Review of facility policy and procedure titled, " Surgical/Procedural Attire " , last approved 4/2014, described the following: For invasive or surgical procedure (including those done outside the OR suite), surgical attire consists of: ... ..., " C. Disposable surgical head covering completely covering the scalp hair. " , ...., " I. All head and facial hair, including sideburns and the nape of the neck, and earrings, should be covered by a Hospital -issued disposable hat or hood in the restricted and semi restricted areas. " , ... ...., " ... ...All jewelry must be removed or confined within the surgical attire, when worn in the semi-restricted and restricted areas of the Surgical Suite. Rings, watches and bracelets may not be worn in these areas, and must be removed before hand washing or using hand rubs. "