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Based on observation, policy review, and staff interviews, the facility failed to ensure everyone entering the restricted area within the surgery department wore the required surgical attire for 2 of 2 observations. The surgery department performs approximately 12,000 surgeries and procedures per year.

Failure to comply with established surgical attire for all individuals who enter the restricted surgery department, could potentially result in exposure to unnecessary and life threatening infections for surgical patients.

Findings include:

1. Observation on 4/16/12 at 3:05 PM, during the tour of the operating room, with Staff E, Executive Director of the Operating Room, revealed Practitioner A, Pathologist, walking down the interior hallway of the restricted surgical department. Practitioner A wore a cover gown that was open in the front, and a surgical hair cover.

Observation on 4/19/12 at 9:30 AM, in the restricted surgical department with Staff G, Surgery Supervisor, revealed 3 male visitors in the Anesthesia workroom located inside the restricted surgical department. The 3 male visitors wore street clothes without the appropriate surgical attire.

2. Review of hospital policy titled "Surgical Attire" revised on 1/2011, revealed in part, "...Policy Purpose: To provide guidelines for attire worn within the semi-restricted and restricted areas of the surgical environment .... Policy Statement: All hospital personnel entering the semi-restricted and restricted areas of the surgery suite will wear operating room attire. Operating room attire includes hospital approved scrub suit, dress, or disposable jumpsuit, cap or hood, shoe covers (optional), warm-up jacket (optional), and name badge, disposable moisture-proof boots or shoe covers are required when significant contamination is anticipated. "

3. During an interview on 4/16/12 at 3:05 PM, Staff E reported past discussions with the Pathologists regarding their surgery attire. Additionally, Staff E acknowledged the Pathologist lacked the appropriate attire to be in the surgery area.

During an interview on 4/19/12 at 10:20 AM, Staff F, Infection Control Registered Nurse, acknowledged the Pathologist lacked the appropriate attire to be in the surgery area.