HospitalInspections.org

Based on observation, interview, and facility document review the facility failed to ensure policies governing surgical care were adhered to for 2 of 32 Patients (24 & 31) when;

1) hair of the operating room (OR) staff was not completely covered during surgical care and,

2) personal protective equipment was not worn by staff during endoscopy (examination of the inside of the body with a lighted instrument) services.

Findings:
1) During a surgical observation of Patient 31 on 2/2/16 at 11:40 a.m., Registered Nurse (RN) 1, RN 2, Medical Doctor (MD) 1, and Operating Room Technician (ORT) 1 were all noted to have blue disposable hair bonnets on that were positioned behind their ears. The hair in front and on top of the ear (sideburn area) was exposed as well as the hair at the nape of the neck of all the staff noted.

During a concurrent interview and observation with RN 1 at 11:40 a.m., she verified the exposed hair of herself, RN 2, MD 1, and ORT 1. RN 1 stated that "OR staff should have their hair covered completely."

Review of the facility policy titled Surgical Attire, Scrub Policy dated 1/13 included the following notation: "All personnel...when going beyond the "red line' or entering the operating room, all hair must be covered by a cap or hood..."

According to the Association of periOperative Registered Nurses (retrieved 2/3/16 from http://www.aornstandards.org/content/1/SEC6.body#psrp_1_ii-attire.s6): "Personnel entering the semi-restricted and restricted areas should cover the head, hair, ears, and facial hair.
Hair and skin can harbor bacteria that can be dispersed into the environment. The collective body of evidence supports covering the hair and ears while in the semi-restricted or restricted areas."

2) The Endoscopy suite was toured on 2/02/16 at 9:00 AM. The Charge Nurse (CN) 1 for the unit was present and conducted the tour. A procedure on Patient 24 was underway and it was noted that the physician was the only person wearing a full face mask/shield. The Gastroenterology Technician (GI Tech) 1, RN 3. and RN 4 had on hair coverings but no mask. They were standing right behind and to either side of the physician, approximately three feet from the procedure table.

CN 1 was questioned and agreed that face masks should be worn while in the procedure room when an endoscopy is taking place.

A hospital policy entitled "Bloodborne Pathogens Exposure Plan" was presented as the policy for OR attire requirements. Section 14, Personal Protective Equipment (PPE) stated that "Employees at risk for occupational exposure shall be provided appropriate PPE at the hospital's expense. The PPE provided includes gloves, gowns, eye protection, face shields or masks ..."