HospitalInspections.org

Based on review of the hospital policy and procedures, observations, and staff interviews, hospital staff failed to wear personal protective equipment (PPE) to cover facial hair in the semi-restricted and restricted areas for 6 of 6 males with facial hair in the semi-restricted and restricted area. (CRNA #1, MD #2, PCT #3, PCT #4, CRNA #5, Vendor #6)

The findings include:

Review on 03/17/2022 of the facility policy titled, "Surgical Attire" with and effective dated 04/2015 revealed " ... B. Restricted area: A designated space contained within the semi-restricted area and accessible only through a semi-restricted area ... includes the operating and other rooms in which surgical or other invasive procedures are performed ... Personnel in the restricted areas should wear surgical attire and cover head and facial hair ... Semi-restricted areas: ... D. Semi-restricted area: The peripheral support areas of the surgical suite. The area may include storage areas ... work areas for processing instruments; sterilization processing room(s); scrub sink areas; corridors leading from the unrestricted area to the restricted areas of the surgical suite; and the entrances to locker rooms, preoperative admission area, the PACU (post anesthesia care unit), and sterile processing ... Personnel in the semi-restricted area should wear surgical attire and cover all head and facial hair ... V. ... J. Personnel entering the semi-restricted and restricted areas will cover the head, hair, ears, and facial hair ... VI. ... G. Head Coverings: ... 2. Cover your beard when entering the restricted areas ..."

Observation on 03/16/2022 between 0925 and 0936 in the main operating room suite revealed a male with facial hair exposed on the sides of his mask. During the observation the male was identified as Certified Registered Nurse Anesthetist (CRNA) #1. Observation revealed CRNA #1 ambulated into operating room #4 without covering his facial hair per policy. Observation revealed a male, identified as MD #2, exiting operating room #6 with facial hair that was not covered by his mask. Observation revealed a male identified as PCT #3 exiting operating room #2 without covering his facial hair per policy. Observation revealed a male identified as PCT #4 ambulating in the restrictive area without covering his facial hair per policy. Observation revealed CRNA #5 exited the Physician lounge and ambulated in the restrictive area without covering his facial hair per policy.

Observation on 03/16/2022 at 1048 in the main operating room suite revealed a male, identified as a vendor representative, (vendor #6) standing in the restrictive area with facial hair that was not covered by the face mask he was wearing.

Interview on 03/16/2022 at 0927 with the Assistant Director #7 revealed the observed males should have their facial hair covered when in the semi-restrictive and restrictive areas, including in the operating rooms. Interview revealed the risk of the facial hair not being covered appropriately could lead to contamination of the sterile field and increases the potential for infection. Interview revealed the hospital has the appropriate PPE including beard coverings for the males to use. Interview revealed the Assistant Director #7 notified the males during the observations to put on beard coverings.

NC00186508