HospitalInspections.org

A. Based on document review, observation, and interview it was determined that for 1 of 1 (E #4) Surgical Technician in Operating Room (OR) #9, the Hospital failed to ensure adherence to the dress code policy.

Findings include:

1. The Hospital's policy entitled, "Dress Code for Surgical Areas," (last reviewed 2/28/18) required, "...2. b. Head and facial hair is completely covered in semi-restricted and restricted areas. This includes side-burns and beards."

2. On 6/6/18 between 9:15 AM and 9:30 AM an observational tour was conducted in OR #9. During the tour, it was observed that E#4 (Surgical Technician) was present in the room assisting in opening sterile supplies with sideburns and facial hair exposed from the sides of his mask.

3. On 06/06/19 at approximately 1:15 PM, during an interview E#6 (OR Manager of Cardiac/Thoracic Surgery) stated that the employee should have had his facial hair covered.

B. Based on observation, document review and interview, it was determined that for 2 of 3 Operating Room Support Assistants -ORSA (E #7 and #8) in Operating Room (OR) #9, the Hospital failed to ensure room cleaning procedures were followed.

Findings include:

1. On 6/6/18 at approximately 9:20 AM, E#7 (ORSA) was cleaning a Jackson Table (table used to position patients for spinal surgery) in OR #9, and E#8 (ORSA) entered the room and began cleaning the lights above the table.

2. The Hospital's policy entitled, "Cleaning The OR/Procedural Areas," (revised: April 3, 2018) required, "...OR/Procedural room cleaning between cases...Clean and disinfect all flat surfaces, Working from higher to lower surfaces...and overhead procedure lights, to help prevent cross-contamination between patients."

3. On 06/06/18at at approximately 9:20 AM, during an interview E #6 stated "The room was being cleaned in the wrong order."