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.
|OSF SAINT ANTHONY MEDICAL CENTER||5666 EAST STATE STREET ROCKFORD, IL 61108||June 8, 2018|
|VIOLATION: OPERATING ROOM POLICIES||Tag No: A0951|
|A. Based on document review, observation, and interview it was determined that for 1 of 1 (E #4) Surgical Technician in Operating Room (OR) #9, the Hospital failed to ensure adherence to the dress code policy.
1. The Hospital's policy entitled, "Dress Code for Surgical Areas," (last reviewed 2/28/18) required, "...2. b. Head and facial hair is completely covered in semi-restricted and restricted areas. This includes side-burns and beards."
2. On 6/6/18 between 9:15 AM and 9:30 AM an observational tour was conducted in OR #9. During the tour, it was observed that E#4 (Surgical Technician) was present in the room assisting in opening sterile supplies with sideburns and facial hair exposed from the sides of his mask.
3. On 06/06/19 at approximately 1:15 PM, during an interview E#6 (OR Manager of Cardiac/Thoracic Surgery) stated that the employee should have had his facial hair covered.
B. Based on observation, document review and interview, it was determined that for 2 of 3 Operating Room Support Assistants -ORSA (E #7 and #8) in Operating Room (OR) #9, the Hospital failed to ensure room cleaning procedures were followed.
1. On 6/6/18 at approximately 9:20 AM, E#7 (ORSA) was cleaning a Jackson Table (table used to position patients for spinal surgery) in OR #9, and E#8 (ORSA) entered the room and began cleaning the lights above the table.
2. The Hospital's policy entitled, "Cleaning The OR/Procedural Areas," (revised: April 3, 2018) required, "...OR/Procedural room cleaning between cases...Clean and disinfect all flat surfaces, Working from higher to lower surfaces...and overhead procedure lights, to help prevent cross-contamination between patients."
3. On 06/06/18at at approximately 9:20 AM, during an interview E #6 stated "The room was being cleaned in the wrong order."