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Based on observation, interviews with patients, interviews with staff, and record review the governing body failed to ensure that patients have the right to make informed decisions and that the policies and procedures of the facility are being followed. These failures resulted in immediate jeopardy.

The findings include:

Observations, interviews with staff, and record review revealed that in four separate findings there is a pattern of non-compliance with the approved policies and procedures of the hospital. Each of these findings in total show that the people responsible for the operation of the facility are not monitoring the daily activities of the entire institution.

The following information document the facility's inability to ensure that patients receive care in a safe and appropriate setting. (See A117; A941; A951)

1. Review of the medical record for Patient #34 revealed she was admitted to the facility for severe peripheral vascular disease and coronary artery disease with worsening left leg pain and ischemia in the left great toe. Patient #34 was scheduled for a right femoral post tibial bypass graft/ in situ, right saphenous vein in the Main Operating Room (OR) on 7/3/13. A surgical consent form was obtained from Patient #34 on 7/2/13 that read left popliteal to posterior tibial bypass and the CV Surgeon marked the left leg. Review of the surgical case record for Patient #34, dated 7/3/13, revealed the actual procedure performed was a right saphenous vein graft open, right common femoral artery endarterectomy with patch, left femoral to popliteal bypass. Review of the Operating Room record revealed no documentation of a time-out procedure being conducted prior to the start of surgery. Review of the medical record revealed no documentation that Patient #34 was informed she was the subject of a wrong site surgery.

Interview with the Clinical Risk Manager on 7/23/13 at 8:30 AM revealed she received a phone call from the Chief Nursing Officer on 7/3/13 informing her of a wrong site surgery performed on Patient #34.

Interview with the Cardivascular Operating Room (CVOR) RN Supervisor on 7/23/13 at 1:00 PM revealed she was the Circulating RN on 7/3/13 for Patient #34's case. She stated there were multiple reasons why a mistake was made on that surgical case. She revealed the surgery was originally scheduled as a right sided femoral/ bypass graft in the Main OR and the CV Surgeon wanted to do the case in the CVOR, so they moved it upstairs. She stated they have been very short staffed and working 12 hour days. She stated, "When I reviewed the schedule with the CV Surgeon, he agreed that he was working on the right leg, so I have read it, and now heard it, and in my mind we are working on the right leg." The CVOR RN Supervisor revealed the OR had to be torn down and set up again because this patient was allergic to latex and required special equipment. In the meantime, the CV Surgeon was asking when they can get started. She stated when she went to talk to the patient and review the procedure with her, the patient stated she was having the left leg done, but she still had it in her mind the right leg. When the patient was brought into the OR both legs were marked and mapped. She stated the Certified Registered Nurse Anesthetist (CRNA) caught the error after the surgery had already been started on the right leg. She revealed that she had been relieved from the OR to go help on another case and wasn't aware of the error until much later in the day. When asked why a time-out was not conducted prior to starting the surgery, she stated, "I swear we did it, and everybody agreed. I guess it doesn ' t matter since we operated on the wrong leg anyway." When asked how the patient was informed, she said the CV Surgeon talked to the patient and family and told them she was probably going to have to have that leg done in the future anyway, so it justified having it done.

Review of the Policy: Pre-Procedure Verification, Identification of Correct Surgical/Procedural Side/Site, Time- Out, dated 4/ 26/12, revealed the following:

Time-Out

A time-out will be done on all operative procedures prior to initiating the procedure.

a. The time-out process will be conducted in the location where the procedure is performed.

b. The time-out process is initiated by a designated member of the team. It involves the immediate members of the procedure team, including the individual performing the procedure, anesthesia providers, the circulating nurse, the operating room technician, and other active participants who will be participating in the procedure from the beginning.

c. The time-out includes:
1. Correct patient
2. Correct side and site: if site marking required, marked and visible
3. Accurate procedure consent form
4. Agreement on the procedure to be done

d. The time-out must be an active pause and a coordinated effort with the entire team including the physician, anesthesia provider when applicable, the scrub and the circulator or involved staff on the care team, and for all invasive procedures performed in non-surgical areas. All extraneous noise and music must be silenced during the time-out procedure.

e. If there is a temporary yellow and white wrist band, it must be included in the time-out.

f. The time-out will be documented in the appropriate procedure record or in the clinical documentation system.

If there is any question by anyone on the team, the procedure will not progress until all concerns are addressed and clarified by the physician.

Interview with the RN First Assistant on 7/25/13 at 9:00 AM revealed on 7/3/13 he relieved the RN Circulator in the CVOR for Patient #34, at 10:30 AM. The procedure had already started and he received report from the CVOR RN Supervisor who was circulating that day. There was no indication at that time of any concerns. He said the room looked a bit disorganized and he spent the first 15 minutes getting everything the way he wanted. Then he noticed the Certified Registered Nurse Anesthetist (CRNA)motioning him to come over to the anesthesia machine where she was located. The CRNA opened the chart to the consent form and he observed the consent and then looked at the surgery site. He stated he observed the surgery being conducted on the right leg and the consent was for the left. At that time he told the CV Surgeon to "STOP." The CV Surgeon stopped, and he informed him that the consent was for the left leg, and you are on the right.

Interview with the CV Surgeon on 7/25/13 at 10:15 AM revealed Patient #34 was scheduled to have a left femoral/popliteal bypass on 7/3/13. He stated when he came in to the OR, the right leg was prepped out. The (case identification) board had a right sided procedure written on it. "I had marked the left thigh on the patient the night before. Unfortunately, with the right side prepped, I thought we were doing the right. The patient was asked what procedure was to be done, but I wasn't there at the time. A time-out was called, but obviously I wasn't paying attention when the time-out was called." The CV Surgeon stated, "I was told by one of the circulators during the case that, 'I think we have a problem, you are operating on the right side, and the patient consent was for the left side.' I had isolated the right saphenous vein but had not taken it out. I broke scrub and went through the chart and reviewed x-rays. I knew the patient was symptomatic on the left side and was also having problems on the right. I felt there was justification for doing the right side with a patch and then we turned our attention to the left side using the right vein for a graft. When I was done with the operation, the Director of Cardiovascular Services and the Chief Medical Officer (CMO) wanted to talk to me. Everybody knew about it including the Chief Executive Officer (CEO), and I don't know who informed them. The next day, the patient's daughter was here, and the patient was alert and oriented. I talked to them, and told them, we operated on the right leg and Administration was worried about not having a signed consent. I explained to them that the surgery was justified because of her history. I then explained to them that I performed the procedure on the left that we obtained the consent for originally, and I asked the patient to sign consent for the procedure that was done on the right leg." When asked if the surgeon told the patient that the surgery performed was considered to be in error, he stated, "No, what I described to the patient was that the right side surgery was justified. I did not use the term 'wrong site surgery.' I said we did not have consent to perform the procedure that we did. I was thinking more about myself and justifying what was done to the patient and what was morally and ethically right. I felt it was enough to say that I did an operation without legal consent. I think that was enough to say to the patient."

Interview with Patient #34 on 7/23/13 at 2:10 PM revealed she has remained a patient in the hospital since her original surgery on 7/3/13. She stated she has had multiple procedures done under anesthesia as a result of both surgical incisions being infected. She further stated the pain has been significant and she had to have a pain pump. The daughter, who was in the room, stated the patient was planning to return to her home after surgery, but now she is going to have to go to a nursing home for further care.

Interview with the Chief Nursing Officer (CNO) on 7/25/13 at 2:10 PM revealed she received a phone call on 7/3/13 at around 3 in the afternoon from the Cardiovascular Service Line Administrator. He advised her there might have been a wrong site surgery in the CVOR. She stated she called the Clinical Risk Manager and the CMO. She stated a meeting was scheduled for 7/5/13 with Risk Management and the attorney. The CV Surgeon was invited, but he did not attend. On 7/8/13, a meeting was held with the Director of Quality, the Clinical Risk Manager, and the entire surgical team. A root cause was discussed, but a single factor was not determined to be the issue; it was determined to be multi-faceted. "We are going to start validating the schedule with the consent." When asked if this had been implemented, she stated, "I can't say if they are doing that yet or not." When asked who was assigned the task of implementing the action plan, she stated, "I don't think we specifically charged a person with that task. The action plan defines the plan but I don't know if we have put down a time line." When asked if any policies or procedures had been changed she stated, "No, policies haven't been changed. I don't know if there have been any in-services yet. I know we want to hire a consultant to come in and discuss time-outs with the staff, but it hasn't happened yet."

2. On July 25, 2013 at 1:50 pm a walk-through of the Adult Psychiatric Center 2500 unit revealed a random observation of 4 patients in the unit who were seated in geriatric chairs with the lap tables locked in place; 1 of 4 in Room 2506 and 3 of 4 in the Dayroom. The observation of the geriatric chairs with the locked lap tables was confirmed by facility's Joint Commission Coordinator who was present during the tour.

Interview on 7/25/13 at 1:54 pm with the Staff RN revealed that some patients use the geriatric chairs and lap tables for lunch and snacks. The patients had lunch on 7/25/13 between 11:30 am and 12:00 pm. She also verbalized that the patients were able to independently remove the lap tables from the Geriatric chairs.

On 7/25/2013 at 2:00 pm, patient observations with the Staff RN revealed that 2 of the patients in the Dayroom were unable to remove the lap tables independently, even with instruction from staff. The 3rd patient in the Dayroom was observed sleeping in the chair with the lap table in place. The patients in the area were not observed eating or drinking.

A staff interview with the Adult Psychiatric Center Unit Manager on 7/25/2013 at 2:20 pm revealed that the Geriatric chairs with the lap tables are not allowed to be used as a restraint, they can only be used during meal times and tea time when patients are eating.

A second visit and observation of the Adult Psychiatric Center 2500 Unit with the Adult Psychiatric Center Unit Manager on 7/25/2013 at 2:25 pm revealed that 2 of the patients in the Day-Room had their lap tables removed. The patient in Room 2506 and 1 patient in the Day-Room remained in the geriatric chair with the lap tables in place. The use of the Geriatric chairs and lap tables were confirmed by the Adult Psychiatric Center Unit Manager. The Adult Psychiatric Center Unit Manager then questioned the staff about why the tables were being used on patients when lunch was not being served. The Adult Psychiatric Center Unit Manager instructed the staff to remove the lap tables from the chairs immediately. The patients in the area were not observed eating or drinking.

A medical record review with the Adult Psychiatric Center Unit Manager of all 4 patients who were observed in Geriatric chairs with the lap tables locked in place revealed there were no active orders for restraints. The Adult Psychiatric Center Unit Manager confirmed through inspection of the electronic and paper medical record there were no physician orders for the patients in question. A review of the nursing notes revealed no documentation to support the need for restraint use.

A staff interview with the Adult Psychiatric Center Unit Manager on 7/25/2013 at 2:35 pm revealed that the staff is not allowed to use to lap tables when meals are not being served, because it is considered a restraint. "This does not usually happen like this in this area, the staff has been educated on this issue."

A staff interview with the Adult Psychiatric Center Unit Manager on 7/25/2013 at 4:16 pm revealed the reason the patients in the Adult Psychiatric Center had the lap tables locked into place on the Geriatric chairs was due to an "all male call" for help on another unit. There were 2 females left on the unit so the lap tables were put in place for safety reasons. She stated when the surveyor visited the unit the men were back in their assigned areas, but had not had a chance to remove the lap tables.

3. While touring the Cardiovascular Operating Rooms (CVOR) with the Clinical Nurse Specialist on 7/23/13 at 9:20 AM, a housekeeper was observed cleaning CVOR #3. The housekeeper brought a cart containing a mop and bucket, and a red plastic bucket to the room. She stated she was going to mop the floor with germicide, clean all the surfaces with germicide, and then mop again. The housekeeper mopped the floor dipping the soiled mop back into the bucket of solution. Then she began to wipe down the OR table using a cloth rag that was dipped in the red plastic bucket containing solution. She stated the solution was germicide that she got from the cleaning closet. The housekeeper dipped the soiled rag into the bucket and wrung it out with her hands and went back to wiping down the OR table. Once again she dipped the soiled rag in the bucket and wrung it out, then went back to wiping down the OR table. She wiped the base of the table, touching the floor and then going back to the sides of the table along with the controls and under the table pads. She dipped the soiled rag back in the bucket and wrung it out. She then proceeded to wipe off the C-arm machine. She dipped the soiled rag back in the bucket and wrung it out, and then proceeded to wipe down the instrument table and the walls. When asked if she was going to change rags, she stated there were a lot of rags in the bucket. She revealed she would change the water after she was done with the room. She repeatedly wiped the floor and then went back to wiping down the sliding doors in the rear of the OR. When she finished wiping down the room, she removed the soiled mop from the bucket and mopped the floor. While exiting CVOR #3, the Clinical Nurse Specialist remarked, "Is that the way OR's are supposed to be cleaned?"

Interview with a Special Procedure Technician in the Main OR on 7/23/13 at 2:30PM revealed he helps clean rooms between cases. He stated the equipment is all sprayed down with a solution labeled HDQ Neutral. The solution is allowed to dry on the surfaces for 8-10 minutes and then the surfaces are wiped down with a disposable cloth that has been sprayed with more HDQ Neutral. He stated new disposable cloths are used on each item cleaned. He stated the last thing to be done is mop the floor. He stated the mop heads are changed after each room use and taken to the laundry for cleaning.

Review of the policy "Operating Room Sanitation" revealed procedure Step 3. C:
Responsibilities of the Special Procedures Technician:
Main OR:
a. Remove trash and linen bags and place in transport containers at the end of the hallway. If suction liner contains fluid, add isolyzer, remove and discard in red bag.

b. Spot clean areas of wall/equipment/lights as needed.

c. Spray and wipe all surfaces of the OR bed, the instrument table, mayo stands, prep table, and sponge counter basket with the approved germicide.

d. Damp mop floors with approved germicidal solution, beginning at the outer perimeter of the sterile field, proceeding to the door. The OR table will be moved to facilitate mopping under it.

e. Replace linen bag, trash bags, sponge counter bags, and suction liners, OR bed should be made as soon as room is clean.

f. Change mop heads after each case, place in a laundry bag and put in soiled linen container. The germicidal solution will be changed daily or when it begins to become visibly clouded.

g. Take bagged soiled trash and linen and place in the appropriate containers. Transport containers should be taken to the decontamination room and emptied when half full.

There was not a separate policy or instructions for cleaning the CVOR.

While touring the surgical area of the Port Orange Hospital with the RN Supervisor on 7/24/13 at 8:00AM, an observation was made of the anesthesia work room. The medication storage area contained 12 vials of Dantrium (a drug used for malignant hyperthermia) 20 milligrams (mg) that expired 4/2013.

The RN Supervisor confirmed that the medication was expired.

While touring the Main OR with the Clinical Nurse Specialist on 7/23/13 at 2:55 PM, 3 unidentified employees wearing scrubs were observed walking in and out of the department without covering their scrubs with a jacket.

Interview with the Main OR Charge Nurse/Supervisor on 7/23/13 at 3:00pm revealed staff wear scrubs from home. She stated they are told what color to wear, but they launder them at home and wear them to work.

Interview with the Clinical Risk Manager on 7/23/13 at 4:00PM revealed the Surgical Department follows the infection control recommendations from the Association of Operating Room Nurses (AORN).

Review of the Recommended Practices for Surgical Attire from AORN Journal 2012 revealed that AORN is taking a stronger stance against home laundering of surgical attire. The practice rationale is that surgical attire and appropriate personal protective equipment in the semi-restricted and restricted areas of health care facilities promotes personnel safety and helps ensure cleanliness in the perioperative environment. Using a health care-accredited laundry facility is preferred because accredited facilities follow industry standards. Perioperative personnel should change into surgical attire in designated dressing areas to decrease the possibility of cross-contamination and to assist with traffic control and should change back into street clothes if they need to leave the facility or travel between buildings to prevent contaminating the surgical attire through contact with the external environment.

Interview with the Infection Control Officer on 7/24/13 at 1:10PM revealed she has made recommendations for hospital provided scrubs. She stated she strongly believes scrubs should not be worn from home and should not be worn back out in public. She stated it is an infection control issue because you don't know what people use to launder clothes at home. She further stated she has received push back from the surgery staff and the medical staff so no changes have been made.

Interview with the Chief Medical Officer on 7/24/13 at 3:10PM revealed he has had discussions with the surgeons about scrubs and shoe covers. He stated the surgeons don ' t want to change things and he likes to defer to their expertise.

4. While touring the Cardiovascular Operating Room (CVOR) with the Clinical Nurse Specialist on 7/23/13 at 10:26AM, an observation was made of Patient #34 going into CVOR #2. The patient was not listed on the Operating Room (OR) schedule. The Registered Nurse (RN) Supervisor stated this was an added case. The RN Circulator revealed the procedure was to be a wound vacuum (vac) change of the right groin, and a possible application of a wound vac to the left groin. The Certified Registered Nurse Anesthetist (CRNA) sedated the patient and the RN Circulator began prepping both groin incisions with betadine. She called out of the room for assistance to hold the patients legs up for prepping because the Certified Surgical Technician (CST) was already scrubbed and dressed. Nobody responded to the call for assistance.

The RN Circulator remarked that they are very short staffed and she doesn't know what everybody is doing. The RN Circulator continued to hold the patient's right leg in the air while waiting for assistance. A Special Procedure Technician (SPT) entered the room to assist the RN Circulator. The RN Circulator remarked that the left groin wound was seeping fluid and she was going to need another wound vac. The SPT replied that those have to be brought up from downstairs and the RN Supervisor had not ordered one.

The procedure started at 11:10 AM with the Cardio-Vascular (CV) Surgeon on the patient's right side and the First Assistant on the left. The wound was explored and irrigated. There was music playing in the CVOR and there was some discussion going on over the patient between the CV Surgeon and the first assistant. The discussion could not be heard; however, the procedure was not progressing. The RN Circulator was asked what was happening and she stated, "The assistant doesn't know how to put the wound vac dressing on, and neither does the doctor." She further revealed this was the First Assistant's second day of employment so they are going to call for someone from the Main Operating Room (OR) to come up and apply the wound vac. At 11:35 AM, a Registered Nurse (RN) First Assistant arrived from the Main OR and began to apply the wound vac to Patient #34's right groin incision. The instruction that the RN First Assistant was giving to the newly hired First Assistant could not be heard over the music playing. The RN Circulator was asked if loud music is always played in the CVOR, and she stated, "This particular doctor likes his music played very loud and it can be distracting." She further stated it is her job to answer the CV Surgeon's cell phone and take a message during a case.

Interview with the CVOR RN Supervisor on 7/23/13 at 1:00 PM revealed the First Assistant just started working the day before. When asked if the First Assistant had received any orientation or completed any competencies, she stated she did not know. She revealed the Cardio-Vascular Service Line Administrator told her the First Assistant could start working on 7/22/13. When asked who is responsible for orientation and training, she stated, "I guess I will be from now on." The CVOR RN revealed that she was new to the position and she told the Cardiovascular Service Line Administrator that she could run the (OR scheduling) board, but she did not know about administrative tasks and she was advised that she would be taught.

Interview with the First Assistant on 7/25/13 at 8:30 AM revealed she began working in the facility on 7/22/13. She stated she has been a Certified Surgical Assistant (CSA) since 2002. She stated on Monday morning, 7/22/13, she talked to Human Resources and went over routine stuff like parking and where to get an identification badge, and then she went to work on her assigned cases. She stated she did not get an orientation to the CVOR. She used to work here for 14 years, but she has been gone for 3 years so she doesn't know if she needs orientation. "I just did my own thing and walked through." She revealed the CVOR RN Supervisor makes out the case assignments. "On 7/23/13, the CVOR RN Supervisor told me to go in to CVOR #3 and help the Cardiovascular (CV) Surgeon with that case. I had never used the wound vac equipment that was used that day. I would have done that different if I had known I was going in there." She stated that she interviewed with the Cardiovascular Service Line Administrator before being hired. "He and I discussed my start date and I put in my 2 week notice, so I could start on 7/22/13. Orientation and competency was never discussed."

Review of the Policy and Procedure "Orientation of OR Personnel" revealed:

All new employees will be provided with a structured, detailed orientation program of the hospital as well as the Cardiovascular Operating Room. This program will begin on the first day of employment and continue through the six month performance appraisal evaluation.

A. All new employees will attend general hospital orientation within the first thirty days of employment.

B. All new employees will attend "Halifax Means Caring" Seminars as assigned.

C. A CVOR orientation packet will be provided to each new employee by the CVOR Charge Nurse, to include:

1. An orientation packet
2. Introduction to staff, physicians, and ancillary personnel
3. A detailed tour of the CVOR suites as well as all other areas of Surgical Services.

D. All new employees will report to the CVOR Manager or designee who will ascertain that the orientation checklist for the department is completed in a timely manner.

E. The CVOR Manager or designee will provide the location of the following information for review and discussion within the first week.
1. Policy and Procedure manual
2. Copy of specific job description
3. Copies of staff meeting minutes
4. Emergency manual

F. All new RNs, surgical technologists, and all surgical assistants will fill out a skills assessment form prior to beginning orientation to patient care. This form will be used to tailor each individual's orientation to his/her needs.

G. All new employees will familiarize themselves with vital areas of Operating Room interactions in the following areas within the orientation period:

1. CVICU
2. CPCU
3. Instrument Room/Case Cart Area
4. Main Operating Room

H. New employees will be assigned to job-specific tasks under the direction of a preceptor following the completion of all above requirements.
1. RNs will initially perform circulating duties in cardiac surgery cases under the direction of the CVOR Charge Nurse.
2. CSTs will initially perform scrub duties in cardiac surgery cases under the direction of an assigned preceptor.
3. Surgical Assistants will initially perform scrub duties in cardiac cases under the direction of an assigned preceptor. After the Surgical Assistant has demonstrated proficiency in the scrub role, the Surgical Assistant will begin to perform First Assistant duties under the direction of an assigned preceptor.
4. Ancillary personnel will perform job-specific tasks under the direction of an assigned preceptor.

I. Computer orientation and training will be done by the CVOR Charge Nurse or designee. A computer entry code will be assigned to appropriate new employees within the first three months employment.

J. Conferences with the CVOR Charge Nurse will be held as needed to assess progress.

K. A performance appraisal evaluation will be given to each new employee at the completion of six months of employment. This evaluation will include input from all members of the surgical team involved in the employee's orientation program.

L. The employee will function as an independent member of the surgical team when the CVOR Manager or designee agrees that basic orientation is complete, and the employee is comfortable.

Interview with the Cardiovascular Service Line Administrator on 7/24/13 at 3:10 PM revealed he had asked for the CSA to be brought on because we were desperate for staff. He further revealed that it was his expectation that she would be brought on through orientation.

Interview with the CV Surgeon on 7/25/13 at 10:15 AM revealed he had talked to Patient #34 on 7/20/13 and advised her she needed to have the wound vac changed on 7/22/13 or 7/23/13. "The procedure could have been done in the Main OR, but I told the RN Supervisor to schedule the procedure in the CVOR on 7/23/13 because I had other cases there that day." He revealed the First Assistant is assigned to a case; he doesn't choose them." It's a small department so there aren't that many to choose from. "He stated he worked with the First Assistant (identified as the new employee) when she worked here before, but she has been gone for several years. "She had scrubbed in on a couple of cases the day before, so I was surprised when she said she didn't know how to use the wound vac." He stated he doesn't apply the dressings, he expects the First Assistant to do that so they can get a good seal.

Based on patient record review and an interview with the Risk Manager and the Cardiovascular Surgeon, the facility failed to inform Patient (#34) in advance of furnishing a surgical procedure.


The findings include:


Review of the Adverse Incident Report submitted on 7/18/13 revealed that Patient #34 was the subject of a wrong site surgery performed on 7/3/13 by the Cardiovascular (CV) Surgeon working in the Cardiovascular Operating Room (CVOR).

Review of the medical record for Patient #34 revealed no documentation to indicate that she was informed of a wrong site surgery having been performed on 7/3/13. Therefore, Patient #34 was not given the opportunity to make an informed decision about her care.

Interview with Patient #34 on 7/23/13 at 2:10PM revealed her care at the hospital has been good. She stated she has had 8-9 surgical procedures since she was admitted. She revealed her first surgery took a really long time because the CV Surgeon decided that she needed to have her right leg operated on as well as her left.

Interview with the Clinical Risk Manager on 7/24/13 at 1:10PM revealed the doctor is the one to tell the patient that they were involved in an adverse incident. She further revealed that disclosure is to be documented in the progress notes.

Interview with the CV Surgeon on 7/25/13 at 10:15 AM revealed he met with Patient #34 and her daughter the day after surgery. He stated he explained to the patient and family that surgery was performed on her right leg without consent and he justified doing it because of her history. He stated he did not tell her it was a wrong site event because he was thinking more about himself and justifying what was done to the patient as morally and ethically right. He further revealed that he asked the patient to sign a consent for the procedure that was already performed.

The patient did not receive appropriate notification of the additional surgery, did not have the opportunity to be aware of the potential risk for the additional surgery, and was not able to make an informed decision about the care that was completed.

Based on observation, medical record review, and staff interviews the facility failed to obtain a physician's order for the application and use of restraints for 4 randomly observed patients.

The findings include:

On July 25, 2013 at 1:50 pm a walk-through of the Adult Psychiatric Center 2500 unit revealed a random observation of 4 patients in the unit who were seated in geriatric chairs with the lap tables locked in place, 1 of 4 in Room 2506 and 3 of 4 in the Dayroom. The observation of the geriatric chairs with the lap tables was confirmed by facility's Joint Commission Coordinator present during the tour.

A staff interview on 7/25/13 at 1:54 pm with Staff RN revealed that some patients use the geriatric chairs and lap tables for lunch and snacks. The patients had lunch on 7/25/13 between 11:30 am and 12:00 pm. She also verbalized that the patients were able to independently remove to lap tables from the Geriatric chairs.

On 7/25/2013 at 2:00 pm, patient observations with Staff RN revealed that 2 of the patients in the Dayroom were unable to remove the lap tables independently, even with instruction from the staff. The 3rd patient in the Dayroom was observed sleeping in the chair with the lap table in place. The patients in the area were not observed eating or drinking.

A staff interview with the Adult Psychiatric Center Unit Manager on 7/25/2013 at 2:20 pm revealed that the Geriatric chairs with the lap tables are not allowed to be used as a restraint; they can only be used during meal times and tea time when patients are eating.

A second visit and observation of the Adult Psychiatric Center 2500 unit with the Adult Psychiatric Center Unit Manager on 7/25/2013 at 2:25 pm, revealed that 2 of the patients in the Day-Room had their lap tables removed. The patient in Room 2506 and 1 patient in the dayroom remained in the geriatric chair with the lap tables in place. The use of the Geriatric chairs and lap tables were confirmed by the Adult Psychiatric Center Unit Manager. The Adult Psychiatric Center Unit Manager then questioned the staff about why the tables were being used on patients when lunch was not being served. The Adult Psychiatric Center Unit Manager instructed the staff to remove the lap tables from the chairs, immediately. The patients in the area were not observed eating or drinking.

A medical record review with the Adult Psychiatric Center Unit Manager of all 4 patients who were observed in Geriatric chairs with the lap tables locked in place revealed there were no active orders for restraints. The Adult Psychiatric Center Unit Manager confirmed through inspection of the electronic and paper medical record there were no physician orders for the patients in question. A review of the nursing notes revealed no documentation to support the need for restraint use.

A staff interview with the Adult Psychiatric Center Unit Manager on 7/25/2013 at 2:35 pm revealed that staff is not allowed to use lap tables when meals are not being served, because it is considered a restraint. "This does not usually happen like this in this area, the staff has been educated on this issue."

A staff interview with the Adult Psychiatric Center Unit Manager on 7/25/2013 at 4:16 pm revealed the reason the patients in the Adult Psychiatric Center had the lap tables locked into place on the Geriatric chairs was due to an "all male call" for help on another unit. There were 2 females left on the unit so the lap tables were put in place for safety reasons. She stated when the surveyor visited the unit, the men were back in their assigned areas, but had not had a chance to remove the lap tables.

Based on patient record reviews, interviews with nursing staff, interview with the Risk Manager and a Cardiovascular Surgeon, the facility failed to ensure that a plan to ensure patient safety was implemented after the analysis of wrong site surgery found an adverse incident; failed to ensure that a comprehensive quality assurance program was in place. (Refer to A 117, A 940, A 941, A0951). The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe setting at Immediate Jeopardy.

Based on patient record review, and interviews with nursing staff, Risk Manager and a Cardiovascular Surgeon, the facility failed to ensure that a plan to ensure patient safety was implemented after the analysis of wrong site surgery found an adverse incident.

The findings include:

An interview with the Risk Manager and Chief Nursing Officer on July 24, 2013 at 3:00 pm, revealed that a wrong site surgery was performed on July 3, 2013. After a review of the facts involved in the case, it was determined that the facility needed to implement changes in the policies, procedures and staff training, to ensure that wrong site surgery does not occur. At the time of the survey, the plan to correct these problems had not been implemented.

Based on observation and staff interviews, the facility failed to ensure that all expired drugs and biologicals were removed from the facility.
The findings include:

While touring the surgical area of Port Orange Hospital with the RN Supervisor on 7/24/13 at 8:00 AM, an observation was made of the anesthesia work room. The medication storage area contained 12 vials of Dantrium (a drug used for malignant hyperthermia) 20 milligrams (mg) that expired 4/2013.

Interview with the RN Supervisor on 7/24/13 at 8:00 AM confirmed that the medication was expired.

Based on staff interviews, medical record reviews, and direct observations, the facility failed to ensure that the surgical services were well organized in accordance with acceptable standards of practice. The facility failed to: 1) take corrective action in response to facility-identified wrong-site surgery, and 2) ensure surgical staff participating in surgery had completed orientation and training. These facility failures resulted in the determination of Immediate Jeopardy.
The findings include:

Refer to the following standards:

A-0941- Organization and Staffing (regarding untrained staff working in the CVOR)

A-0951- Delivery of Service (regarding a wrong-site surgery)

Based on observation, staff interviews, policy and procedure reviews, the facility failed to ensure that personnel working in the Cardiovascular Operating Room (CVOR) were qualified and properly trained.

The findings include:

While touring the Cardiovascular Operating Room (CVOR) with the Clinical Nurse Specialist on 7/23/13 at 10:26 AM, an observation was made of Patient #34 going into CVOR #2. The patient was not listed on the OR schedule. The Registered Nurse (RN) Supervisor stated this was an added case. The RN Circulator revealed the procedure was to be a wound vacuum (vac) change of the right groin, and a possible application of a wound vac to the left groin. The Certified Registered Nurse Anesthetist (CRNA) sedated the patient and the RN Circulator began prepping both groin incisions with betadine. She called out of the room for assistance to hold the patients legs up for prepping because the Certified Surgical Technician (CST) was already scrubbed and dressed. Nobody responded to the call for assistance. The RN Circulator remarked that they are very short staffed and she doesn't know what everybody is doing. The RN Circulator continued to hold the patient's right leg in the air while waiting for assistance. A Special Procedure Technician (SPT) entered the room to assist the RN Circulator. The RN Circulator remarked that the left groin wound was seeping fluid and she was going to need another wound vac. The SPT replied that those have to be brought up from downstairs and the RN Supervisor had not ordered one.

The procedure started at 11:10 AM with the Cardio-Vascular (CV) Surgeon on the patient's right side and the First Assistant on the left. The wound was explored and irrigated. There was music playing in the CVOR and there was some discussion going on over the patient between the CV Surgeon and the First Assistant. The discussion could not be heard; however, the procedure was not progressing. The RN Circulator was asked what was happening and she stated, "The assistant doesn't know how to put the wound vac dressing on, and neither does the doctor." She further revealed this was the First Assistant's second day of employment so they are going to call for someone from the Main OR to come up and apply the wound vac. At 11:35AM, a Registered Nurse (RN) First Assistant arrived from the Main OR and began to apply the wound vac to Patient #34's right groin incision. The instruction that the RN First Assistant was giving to the newly hired First Assistant could not be heard over the music playing. The RN Circulator was asked if loud music is always playing in the CVOR and she stated, "This particular doctor likes his music playing very loud and it can be distracting." She further stated it is her job to answer the CV Surgeon's cell phone and take a message during a case.

Interview with the CVOR RN Supervisor on 7/23/13 at 1:00 PM revealed the First Assistant just started working the day before. When asked if the First Assistant had received any orientation or completed any competencies, she stated she did not know. She revealed the Cardio-Vascular Service Line Administrator told her the First Assistant could start working on 7/22/13. When asked who is responsible for orientation and training, she stated, "I guess I will be from now on." The CVOR RN revealed that she was new to the position and she told the Cardiovascular Service Line Administrator that she could run the (OR scheduling) board, but she did not know about administrative tasks and she was advised that she would be taught.

Interview with the First Assistant on 7/25/13 at 8:30 AM revealed she began working in the facility on 7/22/13. She stated she has been a Certified Surgical Assistant (CSA) since 2002. She stated on Monday morning, 7/22/13, she talked to Human Resources and went over routine stuff like parking and where to get an identification badge, and then she went to work on her assigned cases. She stated she did not get an orientation to the CVOR. She used to work here for 14 years, but she has been gone for 3 years so she doesn't know if she needs orientation. "I just did my own thing and walked through." She revealed the CVOR RN Supervisor makes out the case assignments. "On 7/23/13, the CVOR RN Supervisor told me to go in to CVOR #3 and help the CV Surgeon with that case. I had never used the wound vac equipment that was used that day. I would have done that differently if I had known I was going in there." She stated that she interviewed with the Cardiovascular Service Line Administrator before being hired. "He and I discussed my start date and I put in my 2 week notice, so I could start on 7/22/13. Orientation and competency was never discussed."

Review of the Policy and Procedure, "Orientation of OR Personnel " revealed:

All new employees will be provided with a structured, detailed orientation program of the hospital as well as the Cardiovascular Operating Room. This program will begin on the first day of employment and continue through the six month performance appraisal evaluation.

A. All new employees will attend general hospital orientation within the first thirty days of employment.

B. All new employees will attend "Halifax Means Caring" Seminars as assigned.

C. A CVOR orientation packet will be provided to each new employee by the CVOR Charge Nurse, to include:

1. An orientation packet
2. Introduction to staff, physicians, and ancillary personnel
3. A detailed tour of the CVOR suites as well as all other areas of Surgical Services.

D. All new employees will report to the CVOR Manager or designee who will ascertain that the orientation checklist for the department is completed in a timely manner.
E. The CVOR Manager or designee will provide the location of the following information for review and discussion within the first week.
1. Policy and Procedure manual
2. Copy of specific job description
3. Copies of staff meeting minutes
4. Emergency manual

F. All new RNs, surgical technologists, and all surgical assistants will fill out a skills assessment form prior to beginning orientation to patient care. This form will be used to tailor each individual's orientation to his/her needs.

G. All new employees will familiarize themselves with vital areas of Operating Room interactions in the following areas within the orientation period:
1. CVICU
2. CPCU
3. Instrument Room/Case Cart Area
4. Main Operating Room

H. New employees will be assigned to job-specific tasks under the direction of a preceptor following the completion of all above requirements.
1. RNs will initially perform circulating duties in cardiac surgery cases under the direction of the CVOR Charge Nurse.
2. CSTs will initially perform scrub duties in cardiac surgery cases under the direction of an assigned preceptor.
3. Surgical Assistants will initially perform scrub duties in cardiac cases under the direction of an assigned preceptor. After the Surgical Assistant has demonstrated proficiency in the scrub role, the Surgical Assistant will begin to perform First Assistant duties under the direction of an assigned preceptor.
4. Ancillary personnel will perform job-specific tasks under the direction of an assigned preceptor.

I. Computer orientation and training will be done by the CVOR Charge Nurse or designee. A computer entry code will be assigned to appropriate new employees within the first three months employment.

J. Conferences with the CVOR Charge Nurse will be held as needed to assess progress.

K. A performance appraisal evaluation will be given to each new employee at the completion of six months of employment. This evaluation will include input from all members of the surgical team involved in the employee's orientation program.

L. The employee will function as an independent member of the surgical team when the CVOR Manager or designee agrees that basic orientation is complete, and the employee is comfortable.

Interview with the Cardiovascular Service Line Administrator on 7/24/13 at 3:10 PM revealed he had asked for the CSA to be brought on because we were desperate for staff. He further revealed that it was his expectation that she would be brought on through orientation.

Interview with the CV Surgeon on 7/25/13 at 10:15 AM revealed he had talked to Patient #34 on 7/20/13 and advised her she needed to have the wound vac changed on 7/22/13 or 7/23/13. "The procedure could have been done in the Main OR but, I told the RN Supervisor to schedule the procedure in the CVOR on 7/23/13 because I had other cases there that day." He revealed the First Assistant is assigned to a case, he doesn't choose them. "It's a small department so there aren't that many to choose from." He stated he worked with the First Assistant (identified as the new employee) when she worked here before, but she has been gone for several years. "She had scrubbed in on a couple of cases the day before, so I was surprised when she said she didn't know how to use the wound vac." He stated he doesn't apply the dressings, he expects the First Assistant to do that so they can get a good seal.

Based on medical record review, observations, and policy and procedure reviews, the facility failed to: 1) implement and document standard safety procedures (time-outs) for 1 patient (#34) out of 6 sampled medical records, resulting in a wrong site surgery; 2) enforce proper cleaning procedures for 1 Operating Room (CVOR #2) of 3 observed OR ' s; 3) ensure that expired drugs and biologicals were removed from 1 of 3 medication storage areas; and 4) have written policies following acceptable recommendations or standards for operating room attire.
The findings Include:
1. Review of the medical record for Patient #34 revealed she was admitted to the facility for severe peripheral vascular disease and coronary artery disease with worsening left leg pain and ischemia in the left great toe. Patient #34 was scheduled for a right femoral post tibial bypass graft/ in situ, right saphenous vein in the Main OR on 7/3/13. A surgical consent form was obtained from Patient #34 on 7/2/13 that read left popliteal to posterior tibial bypass and the CV Surgeon marked the left leg.

Review of the surgical case record for Patient #34, dated 7/3/13, revealed the actual procedure performed was a right saphenous vein graft open, right common femoral artery endarterectomy with patch, left femoral to popliteal bypass. Review of the OR record revealed no documentation of a time-out procedure being conducted prior to the start of surgery. Review of the medical record revealed no documentation that Patient #34 was informed she was the subject of a wrong site surgery.

Interview with the Clinical Risk Manager on 7/23/13 at 8:30 AM revealed she received a phone call from the Chief Nursing Officer on 7/3/13 informing her of a wrong site surgery performed on Patient #34.

Interview with the CVOR RN Supervisor on 7/23/13 at 1:00 PM revealed she was the Circulating RN on 7/3/13 for Patient #34's case. She stated there were multiple reasons why a mistake was made on that surgical case. She revealed the surgery was originally scheduled as a right sided femoral/ bypass graft in the Main OR and the CV Surgeon wanted to do the case in the CVOR so they moved it upstairs. She stated they have been very short staffed and working 12 hour days. She stated, "When I reviewed the schedule with the CV Surgeon, he agreed that he was working on the right leg, so I have read it, and now heard it, and in my mind we are working on the right leg." The CVOR RN Supervisor revealed the OR had to be torn down and set up again because this patient was allergic to latex and required special equipment. In the meantime the CV Surgeon was asking when they can get started. She stated when she went to talk to the patient and review the procedure with her, the patient stated she was having the left leg done, but she still had it in her mind the right leg. When the patient was brought into the OR both legs were marked and mapped. She stated the Certified Registered Nurse Anesthetist (CRNA) caught the error after the surgery had already been started on the right leg. She revealed that she had been relieved from the OR to go help on another case and wasn't aware of the error until much later in the day. When asked why a time-out was not conducted prior to starting the surgery she stated, "I swear we did it, and everybody agreed. I guess it doesn't matter since we operated on the wrong leg anyway." When asked how the patient was informed, she said the CV Surgeon talked to the patient and family and told them she was probably going to have to have that leg done in the future anyway so it justified having it done.

Review of the Policy: Pre-Procedure Verification, Identification of Correct Surgical/Procedural Side/Site, Time- Out, dated 4/ 26/12, revealed the following:
Time-Out
A time-out will be done on all operative procedures prior to initiating the procedure.

a. The time-out process will be conducted in the location where the procedure is performed.

b. The time-out process is initiated by a designated member of the team. It involves the immediate members of the procedure team, including the individual performing the procedure, anesthesia providers, the circulating nurse, the operating room technician, and other active participants who will be participating in the procedure from the beginning.

c. The time-out includes:

1. Correct patient
2. Correct side and site: if site marking required, marked and visible
3. Accurate procedure consent form
4. Agreement on the procedure to be done

d. The time-out must be an active pause and a coordinated effort with the entire team including the physician, anesthesia provider when applicable, the scrub and the circulator or involved staff on the care team, and for all invasive procedures performed in non-surgical areas. All extraneous noise and music must be silenced during the time-out procedure.

e. If there is a temporary yellow and white wrist band, it must be included in the time-out.

f. The time-out will be documented in the appropriate procedure record or in the clinical documentation system.

If there is any question by anyone on the team, the procedure will not progress until all concerns are addressed and clarified by the physician.

Interview with the RN First Assistant on 7/25/13 at 9:00 AM revealed on 7/3/13, he relieved the RN Circulator in the CVOR for Patient #34, at 10:30AM. The procedure had already started, and he received report from the CVOR RN Supervisor, who was circulating that day. There was no indication at that time of any concerns. He said the room looked a bit disorganized and he spent the first 15 minutes getting everything the way he wanted. Then he noticed the Certified Registered Nurse Anesthetist (CRNA) motioning him to come over to the anesthesia machine where she was located. The CRNA opened the chart to the consent form and he observed the consent and then looked at the surgery site. He stated he observed the surgery being conducted on the right leg and the consent was for the left. At that time he told the CV Surgeon to "STOP." The CV Surgeon stopped, and he informed him that the consent was for the left leg, and you are on the right.

Interview with the CV Surgeon on 7/25/13 at 10:15AM revealed Patient #34 was scheduled to have a left femoral/popliteal bypass on 7/3/13. He stated when he came in to the OR, the right leg was prepped out. "The (case identification) board had a right sided procedure written on it. I had marked the left thigh on the patient the night before. Unfortunately, with the right side prepped, I thought we were doing the right. The patient was asked what procedure was to be done, but I wasn't there at the time. A time-out was called, but obviously I wasn't paying attention when the time-out was called." The CV Surgeon stated, "I was told by one of the circulators during the case that, 'I think we have a problem, you are operating on the right side, and the patient consent was for the left side.' I had isolated the right saphenous vein, but had not taken it out. I broke scrub and went through the chart and reviewed x-rays. I knew the patient was symptomatic on the left side and was also having problems on the right. I felt there was justification for doing the right side with a patch and then we turned our attention to the left side using the right vein for a graft. When I was done with the operation, the Director of Cardiovascular Services and the Chief Medical Officer (CMO) wanted to talk to me. Everybody knew about it including the Chief Executive Officer (CEO), and I don't know who informed them."

"The next day, the patient's daughter was here, and the patient was alert and oriented. I talked to them, and told them, we operated on the right leg and Administration was worried about not having a signed consent. I explained to them that the surgery was justified because of her history. I then explained to them that I performed the procedure on the left that we obtained the consent for originally, and I asked the patient to sign consent for the procedure that was done on the right leg." When asked if the surgeon told the patient that the surgery performed was considered to be in error he stated, "No, what I described to the patient was that the right side surgery was justified. I did not use the term, 'wrong site surgery.' I said we did not have consent to perform the procedure that we did. I was thinking more about myself and justifying what was done to the patient and what was morally and ethically right. I felt it was enough to say that I did an operation without legal consent. I think that was enough to say to the patient."

Interview with Patient #34 on 7/23/13 at 2:10 PM revealed she has remained a patient in the hospital since her original surgery on 7/3/13. She stated she has had multiple procedures done under anesthesia as a result of both surgical incisions being infected. She further stated the pain has been significant and she had to have a pain pump. The daughter, who was in the room, stated the patient was planning to return to her home after surgery, but now she is going to have to go to a nursing home for further care.

Interview with the Chief Nursing Officer (CNO) on 7/25/13 at 2:10PM revealed she received a phone call on 7/3/13 at around 3:00PM in the afternoon from the Cardiovascular Service Line Administrator. He advised her we might have a wrong site surgery in the CVOR. She stated she called the Clinical Risk Manager and the Chief Medical Officer (CMO). She stated a meeting was scheduled for 7/5/13 with Risk Management and the attorney. The CV Surgeon was invited, but he did not attend. On 7/8/13, a meeting was held with the Director of Quality, the Clinical Risk Manager, and the entire surgical team. A root cause was discussed, but a single factor was not determined to be the issue, it was determined to be multi-faceted. "We are going to start validating the schedule with the consent." When asked if this had been implemented she stated, "I can't say if they are doing that yet or not." When asked who was assigned the task of implementing the action plan she stated, "I don't think we specifically charged a person with that task. The action plan defines the plan, but I don't know if we have put down a time line." When asked if any policies or procedures had been changed she stated, "No, policies haven't been changed. I don't know if there have been any in-services yet. I know we want to hire a consultant to come in and discuss time-outs with the staff, but it hasn't happened yet."

2) While touring the Cardiovascular Operating Rooms (CVOR) with the Clinical Nurse Specialist on 7/23/13 at 9:20 AM, a housekeeper was observed cleaning CVOR #3. The housekeeper brought a cart containing a mop and bucket, and a red plastic bucket to the room. She stated she was going to mop the floor with germicide, clean all the surfaces with germicide, and then mop again. The housekeeper mopped the floor dipping the soiled mop back into the bucket of solution. Then she began to wipe down the OR table using a cloth rag that was dipped in the red plastic bucket containing solution. She stated the solution was germicide that she got from the cleaning closet. The housekeeper dipped the soiled rag into the bucket and wrung it out with her hands and went back to wiping down the OR table. Once again she dipped the soiled rag in the bucket and wrung it out, then went back to wiping down the OR table. She wiped the base of the table, touching the floor and then going back to the sides of the table along with the controls and under the table pads. She dipped the soiled rag back in the bucket and wrung it out. She then proceeded to wipe off the C-arm machine. She dipped the soiled rag back in the bucket and wrung it out, and then proceeded to wipe down the instrument table and the walls. When asked if she was going to change rags, she stated there were a lot of rags in the bucket. She revealed she would change the water after she was done with the room. She repeatedly wiped the floor and then went back to wiping down the sliding doors in the rear of the OR. When she finished wiping down the room, she removed the soiled mop from the bucket and mopped the floor. While exiting CVOR #3, the Clinical Nurse Specialist remarked, "Is that the way ORs are supposed to be cleaned?"

Interview with a Special Procedure Technician in the Main OR on 7/23/13 at 2:30 PM revealed he helps clean rooms between cases. He stated the equipment is all sprayed down with a solution labeled HDQ Neutral. The solution is allowed to dry on the surfaces for 8-10 minutes and then the surfaces are wiped down with a disposable cloth that has been sprayed with more HDQ Neutral. He stated new disposable cloths are used on each item cleaned. He stated the last thing to be done is mop the floor. He stated the mop heads are changed after each room use and taken to the laundry for cleaning.

Review of the policy "Operating Room Sanitation" revealed procedure step 3. C :
Responsibilities of the Special Procedures Technician:
Main OR:
a. Remove trash and linen bags and place in transport containers at the end of the hallway. If suction liner contains fluid, add isolyzer, remove and discard in red bag.

b. Spot clean areas of wall/equipment/lights as needed.

c. Spray and wipe all surfaces of the OR bed, the instrument table, mayo stands, prep table, and sponge counter basket with the approved germicide.

d. Damp mop floors with approved germicidal solution, beginning at the outer perimeter of the sterile field, proceeding to the door. The OR table will be moved to facilitate mopping under it.

e. Replace linen bag, trash bags, sponge counter bags, and suction liners, OR bed should be made as soon as room is clean.

f. Change mop heads after each case, place in a laundry bag and put in soiled linen container. The germicidal solution will be changed daily or when it begins to become visibly clouded.

g. Take bagged soiled trash and linen and place in the appropriate containers. Transport containers should be taken to the decontamination room and emptied when half full.

There was not a separate policy or instructions for cleaning the CVOR.

3. While touring the surgical area of the Port Orange Hospital with the RN Supervisor on 7/24/13 at 8:00 AM, an observation was made of the anesthesia work room. The medication storage area contained 12 vials of Dantrium (a drug used for malignant hyperthermia) 20 milligrams (mg) that expired 4/2013.

The RN Supervisor confirmed that the medication was expired.

4. While touring the Main OR with the Clinical Nurse Specialist on 7/23/13 at 2:55PM, 3 unidentified employees wearing scrubs were observed walking in and out of the department without covering their scrubs with a jacket.

Interview with the Main OR Charge Nurse/Supervisor on 7/23/13 at 3:00pm revealed staff wear scrubs from home. She stated they are told what color to wear, but they launder them at home and wear them to work.

Interview with the Clinical Risk Manager on 7/23/13 at 4:00PM revealed the Surgical Department follows the infection control recommendations from the Association of Operating Room Nurses (AORN).

Review of the Recommended Practices for Surgical Attire from AORN Journal 2012 revealed that AORN is taking a stronger stance against home laundering of surgical attire. The practice rationale is that surgical attire and appropriate personal protective equipment in the semi-restricted and restricted areas of health care facilities promotes personnel safety and helps ensure cleanliness in the perioperative environment. Using a health care-accredited laundry facility is preferred because accredited facilities follow industry standards. Perioperative personnel should change into surgical attire in designated dressing areas to decrease the possibility of cross-contamination and to assist with traffic control and should change back into street clothes if they need to leave the facility or travel between buildings to prevent contaminating the surgical attire through contact with the external environment.

Interview with the Infection Control Officer on 7/24/13 at 1:10PM revealed she has made recommendations for hospital provided scrubs. She stated she strongly believes scrubs should not be worn from home and should not be worn back out in public. She stated it is an infection control issue because you don't know what people use to launder clothes at home. She further stated she has received push back from the surgery staff and the medical staff so no changes have been made.

Interview with the Chief Medical Officer on 7/24/13 at 3:10PM revealed he has had discussions with the surgeons about scrubs and shoe covers. He stated the surgeons don't want to change things and he likes to defer to their expertise.