The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

LITTLE COMPANY OF MARY HOSPITAL 2800 W 95TH ST EVERGREEN PARK, IL 60805 Sept. 6, 2013
VIOLATION: OPERATING ROOM POLICIES Tag No: A0951
Based on document review, observation, and interview, it was determined that for 2 of 7 (E #7, & 8) staff in OR 6, the Hospital failed to ensure adherence to policy relative to appropriate attire in the surgical suite.

Findings include:

1. The Hospital policy titled, "Department of Surgery...Infection Control and Isolation Policy" (revised 2/27/13), required, "The basic principles described here are enforced to create and maintain a aseptic environment in order to ensure safe patient care. ...Appropriate attire for surgical suite: ...Wear protective cover so as to cover all possible head and facial hair..."

2. During observational tour of OR 6, on 9/4/13 between 9:00 AM and 10:00 AM the following was observed:
- The circulating RN, E #7, had 2 inches of hair exposed below the skull cap, at the back of the head.
- The CRNA, E #8, had hair exposed below the bouffant cap.

3. The above findings were discussed with the OR Manager and the OR Clinical Educator during an interview on 9/4/13 at approximately 10:30 AM. The Educator stated that all hair should be covered.