HospitalInspections.org

Based on observation, document review, and interview, it was determined that for 1 of 3 staff (MD#4/ Anesthesiologist) observed preparing intravenous medications, the hospital failed to ensure that hand hygiene was performed as required to prevent the transmission of infection.

Findings include:

1. On 11/29/23 between 9:20 AM and 10:20 AM, an observational tour of the Feinberg 5th floor Operating Room (OR) #7 was conducted. At approximately 9:32 AM, an Anesthesiologist (MD #4) was observed in OR #7 by the Omnicell (medication dispensing system) preparing medication for an upcoming procedure. MD #4 was observed placing an item with a gloved hand into the garbage receptacle then returned to the Omnicell drawer, pulled out a medication vial and proceeded to prepare the intravenous medication. MD # 4 did not remove glove or performed hand hygiene after touching the garbage receptacle.

2. On 11/29/23, the hospital's policy titled, "Hand Hygiene" (revised 1/31/22) was reviewed and required, " ... Hand hygiene is the single most important means for preventing HAI (hospital acquired infections) ... employees, members of the medical staff and house staff ... engaged in direct patient contact or contact with the patient's environment shall adhere to the guidelines regarding hand hygiene practices ... A. Indications for hand hygiene ... 1. When hands are visibly dirty or contaminated ..."

3. On 11/29/23 at approximately 10:30 AM, the above findings were discussed with the Manager of Feinberg 5th floor (E #10). E #10 stated that staff are required to perform hand hygiene after touching a contaminated object or surface. E #10 stated that the Anesthesiologist (MD #4) should have performed hand hygiene after coming into contact with the garbage can and before proceeding with the medication preparation.

Based on observation, document review, and interview, it was determined that for 5 of 5 staff (2 surgical scrub nurses E#12 and E#13, 1 circulating nurse/ E#14, and 2 surgeons MD#4 and MD#5) observed inside the operating room, the hospital failed to ensure that hair was completely covered, as required.

Findings include:

1. On 11/29/23 between 9:20 AM and 10:20 AM, an observational tour of the OR #7 was conducted. At approximately 9:46 AM, a set up for a procedure was initiated by two (2) scrub nurses (E #12 and E #13) and the Circulating Nurse (E #14) was assisting. E #12, E #13, and E #14 all wore hair bonnets; however, there was approximately 2-3 inches of hair exposed at the nape. At approximately 9:52 AM, MD #4 (Anesthesiologist) and MD #5 (Surgeon) entered OR #7 after a sterile field was created with approximately 2 inches of hair exposed at the nape (back of the neck).

2. The hospital's policy titled, "Surgical Scrub Attire" (revised 3/20/19) was reviewed and required, "1. Restricted Area (Operating Rooms): Staff must wear hospital-approved surgical scrub attire. Head and facial hair must be covered in this area."

3. On 11/23/23 at approximately 10:35 AM, an interview was conducted with the Manager of Feinberg 5th floor (E #10). E #10 stated that all hair must be completely covered when entering the restricted and semi-restricted areas of the OR.