HospitalInspections.org

Based on observation, record review and interview, the facility failed to ensure staff are following policy regarding PPE, in 2 of 4 staff observed (C and D). This deficiency directly affects Pt #1 and potentially all 8 Pts receiving surgical services during survey.

Findings include:

Per review on 6/17/14 at 11:15 AM of facility P&P titled Wearing Apparel, n.d., it states under #3 "Use of cover jacket over scrubs may be worn...#5 All personnel should cover head and facial hair, including sideburns and nape of neck in semirestricted and restricted areas."

Per review on 6/17/14 at 4:30 PM of AORN Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings, 2014 Edition, it states under RP: Surgical Attire RP II.a. "Clean surgical Attire, including shoes, head covering, masks and jackets...should be worn in the semirestricted and restricted areas..." RP: Transmissible Infections IV.d. "Health care personnel must wear eye protection when splashes, spray, spatter, or droplets of blood or other potentially infectious materials can be reasonably anticipated."

Per observation of Pt #1's knee surgery on 6/17/14 at 1:09 PM MD C and CRNA D did not have covering all hair covered including side burns, nape and beard, allowing for potential cross contamination. CRNA D did not have on a jacket to cover arms allowing for potential cross contamination due to shedding of skin cells. MD C and CRNA D did not have on eye protection for an orthotic knee procedure that has the potential for spray.

Findings were shared with DIRs RN B and CRNA E in interview on 6/17/14 at 1:30 PM, RN B confirmed the facility uses AORN standards, and agreed staff should follow policies.