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Based on document review and interviews, in 12 out of 12 temperature daily logs, the surgical department did not document corrections to the out of range temperatures in the operating rooms as required by the facilities policy.

This failure to maintain the correct temperature in the operating room has the potential to increase the risk of complications to anesthesia.

Findings include:

The policy and procedure titled " Infection Prevention: Temperature and Humidity Monitoring for the Operative Procedure Areas " last revised 08/2016 Attachment A, states " the temperature and humidity levels will be checked daily " and " the information shall be recorded on the Operating Room Temperature and Humidity Log " . " Engineering will respond and correct any temperature or humidity levels that fall out of recommended range. " There was no documented evidence that the staff was completing this required log form.

The facility policy and procedure titled " Perioperative Services: Environmental Control " last revised 8/2015, states " the standard temperature for the operating room is 68-73 degrees Fahrenheit " and that " the temperature in each OR room is viewed through the Johnson Control Database and printed out on a daily basis. " The policy lacks directions on the steps needed to correct the OR temperatures and document the corrections.

Review of the daily Johnson Control Database temperature and humidity log from 09/03/16 to 9/14/16 revealed that the operating room temperatures were below the required temperature range of 68 to 73 degrees Fahrenheit in multiple OR ' s with no documented evidence of corrections being made.

The daily Johnson Control Database printout on 09/05/16 at 1:26 AM documented the temperatures were below 68 degrees in 9 (nine) operating rooms OR # 5, 6, 8, 10, 12, 14, 19, 22 and C2.

The daily Johnson Control Database printout on 09/08/16 at 2:34 AM, documented the temperatures were below 68 degrees in 9 (nine) operating rooms OR # 1, 6, 8, 10, 14, 19, 21, C1 and C2.

The daily Johnson Control Database printout on 09/11/16 at 6:06 AM documented the temperatures were below 68 degrees in 11 (eleven) operating rooms OR # 1, 5, 6, 7, 10, 11, 12, 14, 18, 19, and 22.

The same missing documentation was identified for the daily temperature logs on 09/03/16, 09/04/16, 09/06/16, 09/07/16, 09/09/16, 09/10/16, 09/12/16, and 09/13/16.

During an interview Staff C (Associate Executive Director of Hospital Operations) in the afternoon of 9/14/15, he stated " Every morning at 5:00 AM the A/C (air conditioning) Shop HVAC (heating ventilation and air conditioning) Mechanics run the report (Johnson Control Database) and adjust the settings to get (the operating rooms) into range. Phone calls are documented in the database but there is no documentation of the adjustments or corrections. "

These findings were verified on interview with Staff D (Director of PST/SDA/PACU), during the afternoon of 09/14/16.

Based on document review and interviews the surgical staff did not maintain an up to date Operating Room patient register. This lack of a current register makes it difficult to determine which patients had surgery each day in case an adverse event occurred.

Findings:

Review of the register on 09/14/16, revealed that the last date the patient information was completed was 9/5/16 nine days earlier.

Review of the Peri-Operative Analytics Office minutes dated 06/24/16 revealed at that time there were over 1100 charts to be entered, the current process had the staff behind for a month worth of data entry, and that new process was being implemented.

An interview with the Staff E (Scheduling Coordinator) during the afternoon of 09/14/16 revealed that "because the information is on paper the data must be entered manually by the staff which causes the lag- time. The back log has improved but the plan to convert a paperless system will not happen until the third quarter of this year or the first quarter of next year."