HospitalInspections.org

Based on observation and interview the hospital failed to maintain infection control standards in the semi-restricted and restricted areas of the surgical procedural suites. This deficiency is evidenced by the failure of the facility to enforce hospital policy on operating room procedural attire regarding the covering of facial hair in three ( S6PA, S8MD, and S9PR) of four (S6PA, S7NA, S8MD, and S9PR) with facial hair in the observed procedure.
Findings:
Review of hospital policy titled, "Procedural Attire," revised 10/2007, in part reveals, "Beards, moustaches, sideburns and neckline, should be covered when in semi-restricted and restricted areas of the surgical suite."

Direct observation on 12/15/2021 of a surgical procedure revealed S6PA and S9PR had facial hair extending outside the facial coverings and S8MD had facial hair and had no facial covering.

During the procedure on 12/15/2021 at 9:25 a.m., S5RN verified the uncovered facial hair of S6PA, S8MD, and S9PR.

In interview on 12/15/2021 at 12:24, S2DON verified the hospital policy that all facial hair should be covered in the surgical suite.