HospitalInspections.org

Based on observation, interview and policy review, the hospital failed to ensure staff followed infection prevention policies for proper Operating Room (OR) attire. The hospital census was 271.

Findings included:

Review of the hospital's policy titled, "Surgical Attire," dated 12/12/22, showed that staff jewelry, including earrings, that could not be contained or confined within the scrub attire should not be worn in the semi-restricted or restricted areas and personal cloth scrub hats must be completely covered by a disposable bouffant hat.

Observation on 03/28/23 at 9:00 AM, showed Staff X, Environmental Services Personnel, with earrings that were not covered by her disposable bouffant hat, while in the hallway of the restricted area within the OR.

Observation on 03/28/23 at 9:02 AM, showed Staff Y, Registered Nurse (RN), and Staff Z, RN, with earrings that were not covered by their disposable bouffant hat, and personal head coverings that were not completely covered by a disposable bouffant hat, while in OR Room 5.

Observation on 03/28/23 at 9:05 AM, showed Staff BB, RN, with earrings that were not covered by her disposable bouffant hat, while in OR Room 7.

Observation on 03/28/23 at 9:10 AM, showed Staff DD, Certified RN Anesthetist (CRNA), with earrings that were not covered by her disposable bouffant hat, while in OR Room 10.

Observation on 03/28/23 at 9:12 AM, showed Staff EE, RN, with earrings that were not covered by her disposable bouffant hat, while in OR Room 11.

Observation on 03/28/23 at 9:13 AM, showed Staff FF, Anesthesia Resident, with a cloth hat that was not covered with a disposable bouffant hat, while in OR Room 12.

Observation on 03/28/23 at 9:14 AM, showed Staff GG, Anesthesia Resident, with earrings that were not covered by her disposable bouffant hat, while in OR Room 15.

Observation on 03/28/23 at 9:15 AM, showed Staff HH, OR Support Technician, with earrings that were not covered by her disposable bouffant hat, while in the hallway of the restricted area within the OR.

During an interview on 03/28/23 at 9:03 AM, Staff U, OR Interim Director, stated that OR staff should have earrings contained within the head covering, and cloth head coverings must be completely covered with a disposable hat.

During an interview on 03/28/23 at 9:04 AM, Staff XX, RN, OR Manager, stated that OR staff should have their earrings covered with the disposable bouffant hat, and any personal head coverings should be completely covered with a disposable bouffant hat.