HospitalInspections.org

Based on observation, staff interview and policy review the facility did not provide services in accordance with acceptable standards of practice. Specifically, facility staff failed to follow facility policy regarding surgical attire.

Findings:

Observation in operating room #6 on 02/23/15 at 10:15am revealed a bilateral total knee replacement surgery in progress. Staff #19, Surgical technician was observed to be wearing a skull cap type of head covering with exposed hair in back of the head and neckline. Staff #13 and #14 verified this observation.

Review on 02/23/15 of policy " Surgical Attire-#SS. " effective 10/3/11 revealed under Head Covering: " Cover all head and facial hair, including sideburns and neckline, with a clean, disposable lint-free hat or hood. A bald or shaved head is covered to prevent shedding of squamous cells. "

Interview on 02/23/15 at 10:15am with Staff #13, Nurse Manager Operating Room and Staff #14, RN, Unit Supervisor regarding facility Policy and Procedure on Surgical Attire, Staff #13 and #14 stated that it is the hospital policy, as well as an AORN (Association of Perioperative Registered Nurses) recommended practice, for all head and facial hair to be completely covered within an operative cap.