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|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.
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.