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BAYLOR SCOTT & WHITE PAVILION - TEMPLE 2401 S 31ST ST TEMPLE, TX 76508 March 5, 2019
VIOLATION: OPERATING ROOM POLICIES Tag No: A0951
Based on observation, interview and record review the facility failed to enforce it's surgical attire policy when surgical staff's had hair exposed out from under the skull caps during surgeries and the staff were not disposing of surgical masks between cases.

Findings include:

Observations on the afternoon of 3/4/19, in the facility's Pre-operative unit revealed the following:

- Staff #5, CRNA walking out of the facility's Operating Room corridor wearing a mask over her mouth and nose. Staff #5 was observed, approximately 10 minutes later, going back into the Operating Room corridor, wearing the same mask. The mask had come down below Staf#5's mouth and nose; Staff #5 readjusted the mask to cover her mouth and nose.

- Staff # 6, RN walking out of the facility's Operating Room corridor wearing a mask tied around his neck. Staff #5 was observed, approximately 15 minutes later, going back into the Operating Room corridor, with the mask now covering his mouth and nose.

During an interview on the afternoon of 3/4/19, in the facility's Pre-operative unit, Staff #3, OR Director corrected the staffs and confirmed the findings.

Observations on the afternoon of 3/5/19, in the facility's Operating Rooms revealed (5) five staff wearing cloth and paper skull caps. The male and female staffs had hair exposed out from under the skull caps.

During an interview on the afternoon of 3/5/19, in the administrative conference room, Staff #17, Infection Control Nurse stated, "We use the facility policy."

Review of the facility provided policy Sterile Procedure/Surgical Attire Document Number: BSW.CLN.009.P (Revision dated 10/02/2018) reflected, " ...5. Hair Covering All Personnel entering the Restricted or Semi-Restricted areas of surgical or procedural suites should wear hair coverings to cover hair on head and facial hair, with the exception of eyebrows and eyelashes.... 6. Surgical Mask - All Personnel entering the Restricted areas should wear a surgical mask when open sterile supplies are present.
- The mask should cover the mouth and nose and be secured in a manner to prevent venting
- A fresh, clean surgical mask should be worn for every procedure ....
- Masks should not be worn hanging down from the neck....
- Surgical masks should be discarded after each procedure...."