HospitalInspections.org

Based on document review and interview, the facility failed to ensure that facility staff followed established policy & procedure and current standard of practice for attire for 1 outpatient surgery area.

Findings include:

1. Review of policy/procedure Dress Code indicated the following:
"Unit Specific Dress Code Guidelines
Central Sterile, Operating Room and Hibbeln Surgery Center - Hospital provided scrub attire."
This policy/procedure was last reviewed/revised on 03-2012.

2. Review of the Standard of Care/Standard of Practice for the Thomas J. Hibbeln Surgery Center indicated the following:
"The nurse will:
5. Follow established guidelines for select procedure/treatment based on infection control strategies. (i.e. dress code, sterile/aseptic techniques, specimen handling.)
References: Association of Perioperative Registered Nurses (2010). Perioperative standards and recommended practices."
This Standard of Care was last reviewed/revised on 07-2010.

3. Review of the Association of Perioperative Registered Nurses (AORN) Recommended Practices for Traffic Patterns in the Perioperative Practice Setting indicated the following:
"The semirestricted area includes the peripheral support areas of the surgical suite. It has storage areas for clean and sterile supplies, work areas for storage and processing of instruments, scrub sink areas, and corridors leading to restricted areas of the surgical suite. Traffic in this area is limited to authorized personnel and patients. Personnel are required to wear surgical attire and cover all head and facial hair. The restricted area includes ORs, procedure rooms, and the clean core area. Surgical attire and hair coverings are required. Masks are required where open sterile supplies or scrubbed persons are located."

4. On 07-12-12 at 0950 hours, staff #41 confirmed that the facility follows AORN standards for dress code in surgical services areas.

5. On 07-12-12 at 1400 hours, staff #42 confirmed that staff #43 will wear street clothes in the center core area and operating rooms approximately one time per week.

6. On 07-12-12 at 1405 hours, staff #45 confirmed that staff #43 will wear street clothes in the center core area and operating rooms.

7. On 07-12-12 at 1415 hours, staff #44 confirmed that staff #43 will wear street clothes in the center core area and operating rooms.

8. On 07-12-12 at 1425 hours, staff #46 confirmed that staff #43 will wear street clothes in the center core area and operating rooms.

9. On 07-12-12 at 1435 hours, staff #47 confirmed that staff #43 will wear street clothes in the center core area and operating rooms.

10. On 07-12-12 at 1455 hours, staff #49 confirmed that staff #43 will not wear proper attire in the center core area and operating rooms.