HospitalInspections.org

Based on policy and procedure review, observations and interviews, it was determined the Facility failed to ensure operating room staff covered all facial and head hair while in the operating room. Failure to ensure all hair was covered had the potential to allow contamination of the surgical instruments, field and wound. The failed practice affected Patient #1 on 01/10/17. Findings follow:

A. Review of the policy and procedure titled "Surgical Services and Central Reprocessing Attire" received from the Chief Quality Officer at 0850 on 01/10/17 revealed the following under: "...V. IMPLEMENTATION, B. Head and facial hair, including sideburns and neckline should be covered when in the semi-restricted or restricted areas of the Surgical Suite. 1. The first item of apparel donned should be clean, low-lint surgical hat or hood that confines the hair. Reusable hats are to be changed daily or whenever visibly soiled or wet...".

B. Observations during Patient #1's surgical procedure revealed the following: Operating Room Technician, Anesthesiologist and Certified Registered Nurse Anesthetist did not have their beards completely covered. The Circulator was observed to have approximately once inch of hair from one ear around the forehead to the other ear uncovered as well as hair at the nape of her neck uncovered. The Operating Room Technician was also wearing a skull cap which was not completely covered by the bouffant cap.

C. During an interview with the Infection Control Nurse at 0745 on 01/10/17 she stated all facial and head hair should be covered.

D. During an interview with the Director of Operating Room Operations at 0805 on 01/10/17 she stated all facial and head hair should be covered.





Based on policy and procedure review, Operating Room (OR) temperature and humidity logs and interview it was determined the Facility failed to ensure the temperature and humidity of the nine operating rooms ranged in the acceptable levels defined by the policy and procedure titled "Operating Room Temperature, Humidity and Air Exchange," numbered OR2007. The failed practice did not allow for patient comfort and had the potential to allow bacterial growth. The failed practice affected all patients who underwent procedures from 12/22/16 through 01/10/17. Findings follow:

A. Review of the policy and procedure titled "Operating Room Temperature, Humidity and Air Exchange" received from the Chief Quality Officer at 1145 on 01/10/17 revealed the following:
"I. PURPOSE: To maintain and abide by Arkansas State Health regulations on OR temperature, humidity and air exchange. ...
IV. Body: Preventive measures to maintain patient temperature should begin in the preoperative phase and continue into the postoperative phase. Peri-operative nursing interventions include adjusting the room temperature within the allowable limits recommended by Arkansas State Health.
V. IMPLEMENTATION:
1. Room temperatures and humidity will be monitored daily by engineering. Documentation of each OR (operating room) temperature and percentage of humidity will be kept in a log book at the surgery front desk.
2. Regulations for Arkansas State Health are as follows:
Temperature in Operating Room 68-73 degrees F
Humidity in Operating Room 20-60%...
3. If the temperature and humidity falls outside the allowable range, engineering will be contacted to investigate and correct the problem.
4. A temperature humidity log will be maintained. This will be generated daily and will include the following components:
a. Temperature
b. Humidity
c. Initials or signature of individual completing the log.
d. Intervention (if applicable)
e. Time intervention carried out.
f. Reassessment of the intervention. ...

B. Review of the OR temperature and humidity logs received from the Infection Control Preventionist at 1130 on 01/10/17 revealed the following dates the rooms were out of range for temperature and/or humidity or did not have readings documented:
01/10/17 8/9 rooms with temperature out of range, 2/9 rooms with humidity out of range
No readings for 01/09/17
01/07/17 8/9 rooms with temperature out of range, 6/9 rooms with humidity out of range
No readings for 01/06/17
No readings for 01/05/17
01/04/17 7/9 rooms with temperature out of range
01/03/17 8/9 rooms with temperature out of range, 2/9 rooms with humidity out of range
01/02/17 7/9 rooms with temperature out of range, 2/9 rooms with humidity out of range
No readings for 12/31/16 à weekend
12/30/16 6/9 rooms with temperature out of range, 1/9 rooms with humidity out of range
12/29/16 8/9 rooms with temperature out of range
12/28/16 8/9 rooms with temperature out of range, 1/9 rooms with humidity out of range
No readings for 12/27/16
No readings for 12/26/16
No readings for 12/25/16 à holiday
No readings for 12/24/16 à weekend
No readings for 12/23/16 à weekend
12/22/16 8/9 rooms with temperature out of range
12/21/16 7/9 rooms with temperature out of range, 1/9 rooms with humidity out of range
12/20/16 7/9 rooms with temperature out of range, 4/9 rooms with humidity out of range
12/19/16 7/9 rooms with temperature out of range, 6/9 rooms with humidity out of range
No readings for 12/18/16
No readings for 12/17/16 à weekend
12/16/16 8/9 rooms with temperature out of range, 1/9 rooms with humidity out of range
12/15/16 8/9 rooms with temperature out of range, 1/9 rooms with humidity out of range
12/14/16 8/9 rooms with temperature out of range, 2/9 rooms with humidity out of range
12/13/16 8/9 rooms with temperature out of range, 4/9 rooms with humidity out of range
12/12/16 7/9 rooms with temperature out of range, 5/9 rooms with humidity out of range
No readings 12/11/16
No readings 12/10/16 à weekend
12/09/16 7/9 rooms with temperature out of range, 1/9 rooms with humidity out of range
The above was verified during an interview with the Infection Control Preventionist and Director of Plant Operations at 1220 on 01/10/17.

C. During the exit conference at 1255 on 01/10/17 the Director of the Operating Room stated she had relied upon the Operating Room Charge Nurse to oversee the temperature and humidity of the operating rooms.