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HOLSTON VALLEY MEDICAL CENTER 130 WEST RAVINE ROAD KINGSPORT, TN 37662 Oct. 14, 2016
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on review of facility policy, observation, and interview, the facility failed to ensure the infection control policy was followed in 1 (#7) operating rooms of 4 operating rooms observed.

The findings included:

Review of the facility policy, Role and Scope of the Infection Prevention Control Program, revised 8/2015, revealed "...All individuals entering restricted areas of the OR (operating room) suite should wear a mask when sterile items are present for an open sterile case. Masks should cover the mouth and nose completely..."

Observation of the OR suite with the Director and Clinical Leader of Surgical Services on 10/12/16 at 6:30 AM, revealed OR rooms #7, #9, #10, and #11 were in use. Continued observation revealed operating room #7 was occupied by a Scrub Technician and a Registered Nurse. Continued observation revealed the surgical sterile equipment and supplies were opened and the sterile field was maintained by the surgical staff. Further observation revealed a surgeon (surgeon #1) entered OR #7 at 6:50 AM with the surgical mask around his neck and not covering his mouth or nose. Continued observation at 6:51 AM revealed Patient #7 was brought into the operating room for an open reduction and internal fixation of the arm. Further observation at 6:53 AM (3 minutes after the surgeon entered OR #7) the surgeon pulled the surgical mask from around his neck and covered the mouth and nose.

Interview with the Director and Clinical Leader of Surgical Services on 10/12/16 at 6:50 AM, in the surgical hallway, confirmed the surgeon failed to cover his mouth and nose with a surgical mask and failed to follow the Infection Control policy and guidelines.