HospitalInspections.org

Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure appropriate use of personal protective equipment, including hair coverage devices and containment of jewelry, in the clean core area and in the operating room and failed to ensure multi-dose vials did not enter the patient room.

Findings include:

1) Review on July 22, 2015, of facility policy "Surgical Attire #10," last reviewed January 2015, revealed "Purpose: To provide guidance to perioperative personnel for surgical attire, including jewelry, clothing, shoes, head coverings, masks, jackets, and other accessories worn in semi restricted areas. Surgical attire and appropriate personal protective equipment (PPE) are worn to promote worker safety and a high level of cleanliness and hygiene in the perioperative environment. The expected outcome is that the patient will be free from signs and symptoms of infection. ... Procedure Interventions Attire in Semi restricted and Restricted Areas ... All perioperative personnel will cover head and facial hair, including sideburns and the nape of the neck. ... Contain all jewelry, including earring, necklaces, watches, and bracelets, within the surgical attire. ..."

Tour of the central core area of the surgical suite at approximately 10:30 AM on July 21, 2015, revealed the facial hair of PF9 was not covered while working in the semi-restricted area. PF9 put on a surgical mask to cover their mustache and beard. Approximately 2" of PF9's sideburns remained uncovered.

Interview of EMP3 at approximately 10:30 AM on July 21, 2015, confirmed the facial hair of PF9 was not covered. Further interview with EMP3 confirmed the surgical mask did not cover PF9's sideburns. EMP3 stated the facility did not have surgical attire available to entirely cover staff facial hair.

Observation in the operating room at approximately 9:00 AM on July 21, 2015, revealed CF2 did not have their earrings, which dangled approximately 1" below the earlobes, contained within their surgical cap.

Interview of EMP3 at approximately 9:00 AM on July 21, 2015, confirmed CF2 did not have their earrings contained within their surgical cap.

2) Review on July 22, 2015, of facility policy "Medication Administration/Medication Record/ADR [Adverse Drug Reaction] Reporting," last reviewed January 2015, revealed "Policy: It is the policy of the Department of Nursing Services to provide a safe environment in which patients may receive their prescribed medication. ... Procedure: A. Roles and Responsibility ... 8. Multi Dose vials - Insulin - are to be wiped down with disinfectant cloth prior to taking to the bedside for scanning. Once scanned and verification obtained - medication is removed from the vial and administered to the patient. The vial will then be cleansed with a disinfectant wipe and returned to [name of medication dispensing equipment]. Please note vials are never taken into isolation rooms - medication verification is done at the entrance of the room. ..."

Observation on July 21, 2015, at approximately 11:35 AM revealed EMP5 administering insulin in Room 515-B after the patient information was scanned. The insulin was withdrawn from a multi-dose vial at the patient bedside.

Observation on July 22, 2015, at approximately 11:35 AM revealed EMP6 administering insulin in room 406-B after the patient information was scanned. The insulin was withdraw from a multi-dose vial at the patient bedside.

Interview at approximately 11:50 AM on July 22, 2015, with EMP7 confirmed the insulin was withdrawn at the patient bedside from a multi-dose vial.