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Based on observation, review of policies and procedures, and interview with staff, the hospital failed to limit access to the surgical department in accordance with their policies for 1 of 1 Practitioners who entered the surgical department lacking proper surgical attire (Practitioner A). The administrative surgical staff reported an average monthly volume of 360 surgical procedures including approximately 20 orthopedic procedures monthly performed by Practitioner A.

Failure to ensure polices are followed related to surgery area protocols in the surgical department could potentially compromise the environment in the surgical area.

Findings include:

1. Observation on 7/14/14 at 12:00 PM, during the initial tour of the surgery department revealed a person dressed in street clothes in the inner corridor of the surgery area. During an interview at the time with Staff A, RN Supervisor Surgical Department, identified the person as Practitioner A, an orthopedic surgeon.
Various staff of the surgery department present in the area failed to stop or question Practitioner A's lack of proper surgical attire at the time of the observation.

2. Review of policy/procedure titled Surgical Attire, dated 4/13, states in part... Purpose: To provide wearing apparel guidelines to promote asepsis and decrease microbial contamination for those authorized persons entering the surgical suite semi-restricted zones. Personnel who enter semi-restricted and restricted areas will wear facility provided surgical attire intended for wear within the surgical suite.

3. During interviews on 7/14/14 at various times, Surgical Staff A, B, C, and D, verified observations of Practitioner A in the central corridor of the surgery department without wearing proper surgical attire. Additional information revealed Practitioner A has been corrected several times regarding the lack of surgical attire in the central corridor but has continued to enter the center surgery corridor in street clothes.

During an interview on 7/14/14 at 12:05 PM, with Practitioner A, revealed the surgeon was aware that the central surgery corridor required surgical attire and admitted this was not the first time the hospital policy was not followed.

During an interview on 7/15/14 at 11:30 AM, Practitioner B, Surgery Chairman, reported being unaware of Practitioner A actions, and agreed that it was not appropriate behavior for a surgeon.