HospitalInspections.org

Based on document review, observation and interview, it was determined that for 3 of 6 staff (E # 3, 5 & 6) observed in the restricted areas of the surgical suite, the Hospital failed to ensure all staff adhered to policies relative to attire.

Findings include:

1. The Hospital policy titled, "OR Attire" (revised 3/14), required, "Divisions of Designated Surgery Suite Areas: Restricted Area-...Masks Required- Operating Rooms ...Center Core. Masks: Masks are to entirely cover both mouth and nose and are to be secured in a manner to prevent venting."

2. During an observational tour of the surgical suite and center core, conducted on 12/18/14 between 10:40 and 11:30 AM, the following was observed:

At approximately 10:55 AM, a Physician Assistant (E #4), entered operating room (OR) 5, where surgical instruments had been opened, from the inner core to obtain a foot stool. E #4's mask was unsecured with the bottom ties hanging down.

At approximately 11:10 AM the surgeon (E #5) entered OR room 5 holding onto his mask, unsecured and then tied the mask after having entered the room with open surgical packs.

At approximately 11:35 AM, a staff (E #6) was in the center core wearing a mask with the bottom ties hanging down, unsecured.

3. The above findings were discussed with the Program Manager during an interview on 12/18/14 at approximately 11:20 AM, who stated that masks should be tied before entering the OR room or the center core.