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.

LENOX HILL HOSPITAL 100 EAST 77TH STREET NEW YORK, NY 10021 Oct. 19, 2015
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, document review and interview, in three (3) of three (3) Operating Rooms (OR), the facility failed to ensure that the proper surgical attire was worn and used correctly by the OR staff.

Findings:

Observations in the facility's Operating Room (OR) Suite during a tour between 11:00 AM and 12:20 PM, on 10/14/15, identified the following failures by staff to comply with the facility's Policy on OR attire:

In OR #11: a Nurse had uncovered studded earrings, a Surgeon had three (3) inches of uncovered hair above the nape of his neck. A Surgical Technician had the sides of his beard and approximately three (3) inches of uncovered hair above the nape of his neck.

In OR #12: a Nurse in the sterile field had approximately two (2) inches of uncovered hair above her forehead. A Physician, Surgeon and a Surgical Technician all had approximately three (3) inches of uncovered hair above the nape of their necks. An Anesthesiologist at the sterile field had uncovered dangling earrings.

In OR #14: a staff member at the sterile field had approximately four (4) inches of hair above the nape of the neck and uncovered sideburns. A Surgeon at the sterile field had approximately three (3) inches of uncovered hair above the nape of the neck. A Circulating Nurse had uncovered earrings and another Nurse had uncovered sideburns.

Observations in the facility's Semi-Restricted Areas; an Environmental Cleaner was noted with his hair and beard exposed. A Surgeon was noted with hair and beard exposed. A Nurse had hair exposed, an unidentified male had his hair and beard exposed, a male had approximately one and one-half (1) inches of his hair and his sideburns exposed.

These findings were acknowledged by Staff #1 the Associate Director Perioperative Services, Staff #2 the Director Perioperative Services, Staff #3 the Director of Epidemiology Department, and Staff #4 the Administrative Executive Director of Patient Care Services, who accompanied the State Agency Surveyor team in the OR areas and observed these issues identified in non-compliance of OR attire and agreed that these were breaches in Infection Control.

Staff #1 stated on 10/14/15 at 12:15 PM, "the skull caps are not specifically mentioned in our current policy, but we were going to change the caps over to everyone wearing the bouton caps. It may just be old stock that is being used up."

Review of the facility's Policy and Procedure titled "Infection Prevention: Perioperative Dress Code Guidelines," last revised 09/12 stated:

"Restricted Area: Includes the OR where surgery is in progress.
Semi-Restricted Areas: Include operating room hallways with direct access to the OR's.
All persons entering the OR rooms or Semi-Restricted Areas of the Perioperative Suites should cover head and facial hear. Men with beards should wear hoods.
Ear and neck jewelry should be removed or totally confined within the head covering/scrub attire and be completely covered in disposable hats or hoods."
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observation and staff interview, in three (3) of three (3) Operating Rooms, the facility failed to ensure that staff provided care in accordance with acceptable Standards of Infection Control Practices and facility Policies and Procedures to avoid potential sources of cross contamination.

This lapse in infection control practice may have placed all patients at risk for exposure to hospital acquired infections.

Findings:

See Citation: Tag A 749.