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.

ELMHURST MEMORIAL HOSPITAL 155 EAST BRUSH HILL ROAD ELMHURST, IL 60126 Dec. 19, 2014
VIOLATION: OPERATING ROOM POLICIES Tag No: A0951
Based on document review, observation and interview, it was determined that for 3 of 6 staff (E # 3, 5 & 6) observed in the restricted areas of the surgical suite, the Hospital failed to ensure all staff adhered to policies relative to attire.

Findings include:

1. The Hospital policy titled, "OR Attire" (revised 3/14), required, "Divisions of Designated Surgery Suite Areas: Restricted Area-...Masks Required- Operating Rooms ...Center Core. Masks: Masks are to entirely cover both mouth and nose and are to be secured in a manner to prevent venting."

2. During an observational tour of the surgical suite and center core, conducted on 12/18/14 between 10:40 and 11:30 AM, the following was observed:

At approximately 10:55 AM, a Physician Assistant (E #4), entered operating room (OR) 5, where surgical instruments had been opened, from the inner core to obtain a foot stool. E #4's mask was unsecured with the bottom ties hanging down.

At approximately 11:10 AM the surgeon (E #5) entered OR room 5 holding onto his mask, unsecured and then tied the mask after having entered the room with open surgical packs.

At approximately 11:35 AM, a staff (E #6) was in the center core wearing a mask with the bottom ties hanging down, unsecured.

3. The above findings were discussed with the Program Manager during an interview on 12/18/14 at approximately 11:20 AM, who stated that masks should be tied before entering the OR room or the center core.