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AIA, (American Institute of Architects) Guidelines for Design and Construction of Health Care Facilities Under the 2006 edition, section 2.1, 8.2.3.4 it states in part:

(3) Semirestricted areas

(a) Ceiling finishes in semirestricted areas such as airborne infection isolation rooms, protective environment rooms, clean corridors, central sterile supply spaces, specialized radiographic rooms, and minor surgical procedure rooms shall be smooth, scrubbable, nonabsorptive, nonperforated, capable of withstanding cleaning with chemicals, and without crevices that can harbor mold and bacterial growth.

(b) If lay-in ceiling is provided, it shall be gasketed or clipped down to prevent the passage of particles from the cavity above the ceiling plan into the semirestricted environment. Perforated, tegular, serrated cut, or highly textured tiles are not acceptable.

(4) Restricted areas. Ceiling finishes in restricted areas such as operating rooms shall be monolithic, scrubbable, and capable of withstanding chemicals. Cracks or perforations in these ceilings are not allowed."


AORN Standards Recommended Practices and Guidelines - Traffic patterns should be designed to facilitate movement of patients and personnel into, through, and out of defined areas within the surgical suite. Signs should clearly indicate the appropriate environmental controls and surgical attire required.

1) The surgical suite should be divided into three designated areas that are defined by the physical activities performed in each area. Increasing environmental controls and surgical attire as progressions made from unrestricted to restricted areas decreases the potential for cross-contamination.

Unrestricted areas... Central control point that is established to monitor the entrance of patients, personnel and materials, street clothes are permitted...

Semirestricted area...storage areas for clean and sterile supplies, work areas for storage and processing of instruments, and corridors leading to the restricted areas of the surgical suite. Traffic in this area is limited to authorized personnel and patients. Persons in this area should wear surgical attire...

Restricted areas include operating and procedure rooms, the clean core, and scrub sink areas. Persons in this area are required to wear full surgical attire ...

2) Movement of personnel from unrestricted areas to either semirestricted or restricted areas should be thorough a transition zone. A transition zone exists where one can enter the area in street clothing and exit into the semirestricted or restricted zone in surgical attire...

Based on observation and interview the facility failed to restrict patient and equipment traffic from unrestricted to semi restricted corridor and failed to have smooth, scrubbable, nonabsorptive, nonperforated, ceiling tiles in the area outside of the procedure room which is currently being used as a semi restricted corridor.

Findings include:

Observation during tour of the facility's surgical suite on 6/25/13 revealed that the ceiling tiles located directly outside of the procedure room are not smooth, scrubbable, nonabsorptive, and nonperforated, as required in a semi restricted corridor. The procedure room is currently being used for endoscopy procedures and the corridor outside the procedure room is being utilized as a semi restricted corridor on days when endoscopy procedures are scheduled. On days when pain management patients are scheduled the same corridor is being used as an unrestricted corridor. Patients and equipment are being transported through the unrestricted corridor located directly adjacent to the procedure room through the double doors that enter the Operating Room suite, through the semi restricted corridor outside of Operating Rooms 1 & 2 and into the PACU, Post Anesthesia Care Unit. This traffic pattern does not meet standards as listed above.

Interview on 6/25/13 with Staff B (RN Director of Surgical services) confirmed that the ceiling tiles located directly outside of the procedure room are not smooth, scrubble, nonabsorptive and nonperforated as required in a semi restricted corridor. The procedure room is currently being used for endoscopy procedures and the corridor outside the procedure room is being utilized as a semi restricted corridor on days when endoscopy procedures are scheduled. On days when pain management patients are scheduled the same corridor is being used as an unrestricted corridor. Patients and equipment are being transported through the unrestricted corridor located directly adjacent to the procedure room through the double doors that enter the Operating Room suite, through the semi restricted corridor outside of Operating Rooms 1 & 2 and into the PACU, Post Anesthesia Care Unit. This traffic pattern does not meet standards as listed above.

Based on record review and interview the facility failed to conduct fire drills at least quarterly on each shift.

Findings include:

Review of facility records revealed the facility has two shifts, the first shift, 7 a.m. to 7 p.m. and second shift 7 p.m. to 7 a.m.. Records revealed that fire drills for the fourth quarter of 2012 and the first quarter of 2013 were only done on the first shift.

Interview of Staff A (Director of Maintenance) confirmed that the facility has two shifts, the first shift, 7 a.m. to 7 p.m. and second shift 7 p.m. to 7 a.m. and that the fire drills for the fourth quarter of 2012 and the first quarter of 2013 were only done on the first shift.