HospitalInspections.org

Based on a review of facility documents, observation and staff interview (EMP), it was determined that Moses Taylor Hospital failed to ensure all hair was restrained by hair restraints for staff working in their Dietary Department and failed to ensure their Pharmacy staff wore face masks that covered the entire nose and mouth in the sterile Intravenous Preparation room.

Finding include:

1) Review of the facility Uniform Dress Code Policy #E004 policy, last revised November 25, 2014, revealed, "Policies: Personal cleanliness and a neat appearance are essential for the food service worker. Procedures: ... Wear the approved hair restraint when on duty. The only exception is to remove the hair restraints when delivering trays to patients/residents. Elaborate hair styles are not suitable for foodservice work. Decorative beads and other hair ornaments which may come loose and fall in the food may not be worn. Sweatbands are prohibited. Long facial hair must be covered with a surgical mask and/or hood. Mustache and/or sideburns must be neatly trimmed. ... ."

Observation tour on January 11, 2017, at approximately 9:45 AM revealed a sign posted on the entry door to the facility Food Service Department. This sign stated, "Dietary Personnel Only - Hats or Hair Nets To Be Worn Beyond This Point."

Observation of EMP17 on January 11, 2017, at approximately 9:40 AM revealed this employee exit the facility Dietary Department. Further observation revealed EMP17's hair was hanging below the hairnet.

Interview with EMP11 and EMP19 on January 11, 2017, at the time of the observations confirmed EMP17 was in the facility Dietary Department and this employee's hair was hanging below the hairnet.

Observation of EMP18 on January 11, 2017, at approximately 9:45 AM revealed this employee's facial hair not restrained with a cover.

Interview with EMP18 on January 11, 2017, at the time of the observation confirmed this employee's facial hair was not covered while working in the Dietary Department. Further interview revealed the facility does not have a policy addressing covering facial hair when working in the Dietary Department.

Observation of EMP19, EMP20 and EMP21 on January 11, 2017, revealed these employees preparing food for patient consumption without all hair restrained in the hairnet.

Interview with EMP11 and EMP18 on January 11, 2017, at the time of the observations confirmed EMP19, EMP20 and EMP21 were preparing food for patient consumption without all hair restrained in the hairnet.

2) Review of the facility 30-0350 - Donning for CSP [Compounding Sterile Preparations] in Clean Room Policy, last revised January 4, 2016, revealed, "I. Purpose: A. To provide a standard was for each member of the Pharmacy staff, responsible for compounding sterile preparations, to follow while entering, being in, and leaving the Clean Room. ... A. Applicable Staff: All Pharmacist and Technicians, who compound IV [intravenous] and syringe products II. Procedure: A. Prior to entering the Buffer and Ante area: 1. Remove outer lab jackets 2. Remove makeup that causes shedding or flaking 3. Remove jewelry that interferes with the fit of gloves or cuffs. 4. Remove gum or candy, 5. Do not bring food in to the Clean Room or Anteroom B. In the Ante Area, prior to entry into designated Clean Area complete the following sequence: 1. Don shoe covers 2. Don head cover and facial hair 3. Place on face mask 4. Scrub hands and arms up to the elbow with soap using a scrub brush on the fingers and nails using friction for at least 30 seconds. 5. Dry thoroughly hands and arms with either an air dryer or a disposable non-shedding (lint-free) towel. 6. Don non-shedding coat, gowns or overall that has a closed front and snug fitting wrists C. In Buffer Area 1. Cleanse hands with alcohol based product 2. Allow hands to dry 3. Don Sterile Gloves ... ."

Observation on January 11, 2017, of the entry door to the Intravenous (IV) Preparation Room in the facility Pharmacy revealed a sign that stated, "Please be properly attired when going into this room. Thank You for 100 % Compliance"

Interview with EMP14 on January 11, 2017, at approximately 8:55 AM revealed this IV Preparation Room is a sterile area, this room is used for the preparation of IV fluids and drawing medications into syringes.

Observation of EMP15 on January 11, 2017, at approximately 8:55 AM revealed this employee's face mask positioned under their nose and not covering their nose.

Observation of EMP16 on January 11, 2017, at approximately 8:55 AM revealed this employee's face mask gathered under their chin and not covering their nose or mouth.

Interview with EMP14 on January 11, 2017, confirmed EMP15 and EMP16 face masks were not covering these employees nose and mouth; this is a sterile room and all employees working in this area are required to wear the face mask over their nose and mouth to ensure sterility of the area and the medication preparation.