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OSF LITTLE COMPANY OF MARY MEDICAL CENTER
OPERATING ROOM POLICIES
Tag No.: A0951
Based on document review, observation, and interview, it was determined that for 2 of 7 (E #7, & 8) staff in OR 6, the Hospital failed to ensure adherence to policy relative to appropriate attire in the surgical suite.
Findings include:
1. The Hospital policy titled, "Department of Surgery...Infection Control and Isolation Policy" (revised 2/27/13), required, "The basic principles described here are enforced to create and maintain a aseptic environment in order to ensure safe patient care. ...Appropriate attire for surgical suite: ...Wear protective cover so as to cover all possible head and facial hair..."
2. During observational tour of OR 6, on 9/4/13 between 9:00 AM and 10:00 AM the following was observed:
- The circulating RN, E #7, had 2 inches of hair exposed below the skull cap, at the back of the head.
- The CRNA, E #8, had hair exposed below the bouffant cap.
3. The above findings were discussed with the OR Manager and the OR Clinical Educator during an interview on 9/4/13 at approximately 10:30 AM. The Educator stated that all hair should be covered.