HospitalInspections.org

The Hospital data based worksheet completed by the hospital reported they staffed 32 of 34 beds with a current census of 3. Twenty three patients were sampled. Based on document review and staff interview the hospital failed to provide in-patients and out-patients at admission the State complaint hotline number for the State agency for 3 patients admitted to the hospital.

Findings include:

- The "Patient Rights" reviewed on 4/2/13 at 4:30pm given to in-patient's and out-patient's at admission time lacked the State complaint hotline number.

Administrative staff A interviewed on 4/2/13 at 11:43am acknowledged the Hospital failed to post or provide the State Agency hotline complaint number to patients in the Patient Rights.

The Hospital data based worksheet completed by the hospital reported they staffed 32 of 34 beds with a current census of 3. Twenty three patients were sampled. Based on observations, policy review, and staff interview the Hospital's surgical staff failed to follow hospital policies and follow AORN guidelines for the wearing of hair covers.

Findings include:

- Hospital policy "Surgical Attire" reviewed on 4/3/13 at 1:30pm directed " All persons entering the OR corridor must be dressed in proper surgical attire ...includes a clean scrub suit, cap and shoe covers and/or appropriate dedicated shoes for the OR ...all head and facial hair is to be completely covered in the surgical areas ..."

AORN 2012 Recommendation IV reads: "All personnel should cover their head and facial hair when in the semi-restricted and restricted areas. Hair coverings should cover facial hair, sideburns and the nape of the neck ...Skulls caps are not recommended because they do not completely cover the wearer's hair and skin: they fail to cover the side hair above and in front of the ears and the hair at the nape of the neck."

- Multiply surgical staff and physicians observed on 4/2/13 from 8:30am to 12:15pm revealed multiple surgical staff and physicians wore hair covers which failed to cover their hair at the nape of their neck, around their ears and their sideburns. For example:

Physician staff B on 4/2/13 at 8:30am wore a surgical "skull" cap hair cover that failed to cover all of their head hair, the hair at the nape of their neck, the hair around their ears and sideburns.

Scrub Technician C on 4/2/13 at 9:30am wore a disposable surgical "skull" cap hair cover that failed to cover all of their head hair, the hair at the nape of their neck, the hair around their ears and sideburns.

Administrative staff A interviewed on 4/2/13 at 2:30pm verified OR staff and physicians practicing at the hospital failed to follow AORN guidelines and hospital policy to cover all head hair and sideburns.