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A. Based on observation, interview and document review, it was determined that the Hospital failed to ensure the patient and staff corridors were free of equipment and clutter. This potentially affects safe exit of staff and patients being transported from the operating room suites.

Findings include:

1. On 05/15/2018 at approximately 8:50 AM, during the observational tour of the surgical services the following were found:

-The hallways for operating rooms 1, 2, and 3 had several pieces of equipment on both sides of the hallways: one cart of saline, one abdominal surgery equipment cart, one bladder surgery equipment cart, 2 case carts, light equipment for eye cases, and 3 fully loaded supply carts. The walkway to the exit was cluttered with equipment.

-The hallways for operating rooms 4, 5 and 6 had several equipment on both sides of the hallways: three supply carts for the operating rooms and four supply carts for the cardiovascular (heart) room.

-There were four metal case carts in the operating room 7 hallway containing sterile equipment. Approximately 10 -15 sterile packs were kept on all the metal carts, covered with white sheets. A supply tray and 8 - 10 clean blankets were also on top of the white cover sheet.

-The hallways for operating rooms 8 and 9 had several pieces of equipment on both sides of the hallway: two empty patient carts, one anesthesia machine, six suction machines and an environmental cart left unattended, along with the buffing machine.

2. At approximately 9:40 AM, during the surgical services tour, E #1 (Director of Surgical Services) stated, "We moved a lot of stuff from our other Hospital on 02/26/2018. I prefer not having all these [this] equipment in the hallway around the operating rooms. We will have the storage area built and ready to move all these [this] equipment by the end of the month."

3. At approximately 10:02 AM, E #2 (Vice President of Clinical services) stated, "We are in the process of building the storage space." E #1 stated, "I did not realize this much of overflow would occur."

4. The Hospital's policy titled, "Alternative Life Safety Measure Procedure Policy," (11/11/16) included, "Procedure: ...1. Ensuring exits provide free and unobstructed egress ..."


B. Based on observation, interview and document review, it was determined that for 1 of 5 (E #5) personnel observed, the Hospital failed to ensure adherence to appropriate attire within the surgical environment.

Finding include:

1. On 05/15/2018 at approximately 9:45 AM, during the observational tour of the surgical environment, E #5 (Anesthesia Assistant Medical Director) was observed walking into operating room #8 with approximately 2 inches of hair exposed in the back of his head.

2. The above was witnessed by E #1 (Director of Surgical Services) who was interviewed on 5/15/18 at approximately 9:45 AM, and stated, "Well it's exposed hair, it should all be covered."

3. The Hospital's policy titled, "Attire, Operating Room Policy," (Rev. 11/2017) included, "Section: Surgical Services ...Key Points: B. Personal must cover head and facial hair, including ...and neckline ...1. A clean surgical head cover or hood that confines all hair must be worn."