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Based on observation, interview and document review, the facility failed to ensure that all personnel in the operating room follow acceptable standards for surgical patient care. Specifically, the facility failed to enforce its policy relating to acceptable surgical attire.

Findings:

A surgical tracer case was observed on 9/21/18 beginning at 11:30AM. Two surveyors were accompanied in the Operating Room (OR) by an Infection Control Nurse who was formerly an OR nurse.

Procedures, activities and the OR environment were observed for regulatory compliance and compliance with facility policies and procedures. Staff involved in the case were the Surgeon, the Surgical Resident, the Anesthesiologist, the scrub technician and the RN circulator.

Upon observation it was noted that the Anesthesiologist was wearing a short- sleeved scrub type top for the entire procedure. This garment failed to provide the maximum skin coverage as required by Regulation and facility policy " #660.2350, Surgical Attire in Perioperative Environment", effective 11/05, revised 4/18. The policy states that "When in the restricted area, non-scrubbed
personnel should wear a long sleeve scrub jacket which covers the arms".

This observation finding was verified upon interview with the Director of Surgical Services and the Infection Control Nurse on 9/21/18 at 1:45pm. The surgical short-sleeved scrub worn by the Anesthesiologist did not provide the required skin coverages as required by AORN (Association of Operating Room Nurses ), a National Organization that the facility adopted as the guideline for the facility policy. Facility policy #660.2350 was also not followed or enforced.

Failure to maintain these standards increases the patient's risk of exposure to microorganisms that shed from human skin and hair and increases the risk of a surgical infection.