HospitalInspections.org

1. Based on reviews of logs, reports, and interviews, the Governing Body failed to analyze Quality Assurance Process Improvement data and to maintain a sanitary environment.


The findings included:


a. Based on reviews of available Humidity and Temperature logs of the hospital's operative suite from April 2016 thru August 2016 and including this survey revealed the temperature and humidity far exceeded the recommended guidelines of nationally accepted standards of practice as well as the policy and procedures used by the hospital. The conditions of the operative suite was such that the staff utilized de-humidifiers in areas of the suite to keep the moisture off the walls and floors. Cultures taken from the operative suite were positive for bacterial growth however the administration continued to allow surgical and Endoscopy procedures to be performed while exposing patients to unnecessary risks of health care acquired infections.


b. Based on reviews of the Operating Room Log conducted on 8/2/16 revealed 46 patients had procedures performed in the operative suite since 7/1/16 thru 8/1/16 following a disruption of air conditioning throughout the entire hospital. The disruption required multiple contractors to address the issue beginning on or about 7/1/16 to 7/3/16 according to staff member S1 who also acknowledged having to buy fans for other areas of the hospital. The laboratory and radiology department also affected by temperature and humidity have provided controls proving they were operating within safe parameters. At the time of this survey the only area still affected is the operative suite.


c. There was no evidence the hospital's administration acted on the information collected for QAPI and Infection Control which was readily available as well as the physical conditions of the suite from April thru August 2016.


d. Interviews with S1 and S2 conducted throughout the survey process, they both maintained they were not aware the temperature and humidity of the operative suite exceeded recognized standards as well as their own policies and procedures based on the same nationally recognized standards of practice.

Based on observations, interviews, and record reviews, the hospital performed procedures in operating rooms where the humidity and temperature were not maintained in accordance with nationally accepted standards of practice as required. The American Society for Heating, Refrigeration, and Air conditioning Engineers (ASHRAE) Standard 170, Ventilation of Health Care Facilities Addendum D requires relative humidity in operating rooms to be maintained between 20-60 percent. The acceptable standard for operating room temperature is between 68 and 75 degrees F as recommended by the Association of periOperative Registered Nurses (AORN). Excessive humidity is conducive to microbial growth and placed the patients undergoing procedures in these operating rooms at risk for infections affecting the quality of care provided.

During a tour of the three operating rooms accompanied by S3 on 08/02/16 beginning at 12:37 p.m. observations revealed the following:

a. At 12:37 p.m., the wall hygrometer and temperature indicator read 91% humidity and 70 degrees F in surgical room A referred to as " OR A " by S3 who stated "A is down and not used." The humidity and temperature taken by S3 with a Digital Thermo/Hygrometer read 81% and 72 F. S3 stated that, "I've been using the Digital Thermometer and Hygrometer since January to take the readings because I want accurate readings" and confirmed the humidity and temperature logs reflect these readings.

b. At 12:43 p.m., the wall hygrometer and temperature indicator read 86% humidity and 70 degrees F in surgical room B referred to as "OR B" by S3 who stated, "B is used for 99% of general surgery cases and laparoscopic surgery." The humidity and temperature taken by S3 with a Digital Thermo/Hygrometer read 76.7% and 72.9 F.

c. At 12:46 p.m., the wall hygrometer and temperature indicator read 79% humidity and 76 degrees F in the Minor Surgery room referred to as "OR C or the scope room" by S3. The humidity and temperature taken by S3 with a Digital Thermo/Hygrometer read 67.2% and 78.5 F. The Minor Surgery room or "scope room" had two doors and one door remained open to the corridor. When asked about the door being left open to the corridor, S3 stated, "It is left open to attempt to keep the room at a more controlled temperature than it would be if it were closed." A Frigidaire dehumidifier was observed sitting on a rolling cart in front of an endoscope hanging on the wall. A black hose was connected to the dehumidifier and the other end of the hose rested in clear liquid at the bottom of an open gray plastic four sided container. When asked about the dehumidifier, S3 stated, "At some point during the 14th to 18th of July we got de-humidifiers for each room and ran them between cases if applicable. It keeps the condensation down. The catch basket is emptied each morning and on the week-end the house supervisor is doing it. At some point roughly between July 18th and 25th room B got to a point where we felt it didn't need a dehumidifier so we took it out."

d. During a tour of the instrument room accompanied by S3 on 08/02/16 at 1:30 p.m., the humidity and temperature taken by S3 with a Digital Thermo/Hygrometer read 51.2% and 77.2 F.

e. During a tour of the sterile processing room accompanied by S3 on 08/02/16 at 1:58 p.m., the wall hygrometer and temperature indicator read 85% humidity and 70 degrees F. The humidity and temperature taken by S3 with a Digital Thermo/Hygrometer read 64% and 72 F.

In interviews on 08/02/16 at 12:46 p.m., 1:30 p.m. and 1:58 p.m., S3 confirmed the above findings.

Review of the hospital's temperature and humidity log on 08/02/16 at 12:48 p.m. for 08/02/16 revealed that the humidity was 82.4% in A, 82.7% in B and 79.0% in C. The temperature was 68.4 degrees F in A, 67.9 degrees F in B and 71.1 F degrees in C.

Review of a handwritten list dated 07/13/16 that was provided on 08/02/16 by S3 and identified by S3 as lab results of "swabs taken of vents all over the department" revealed the following: "Pre-op - Growth" and "Ster. Hallway - growth."

Review of the hospital's perioperative records, temperature and humidity logs on 08/02/16 at 3:30 p.m. for the time period from 07/01/16 to 08/02/16 specifically revealed the following on days in which procedures were performed:

a. On 07/01/16 the humidity was 74.1 and temperature 65.9 in OR B. P1 had a "Left Above Knee Stump Revision," and P2 had an "Excision of Mass Right Forearm, Mass Left Lower Back, Melanotic Nevus Left Upper Back" performed in OR B on 07/01/16.

b. On 07/05/16, the humidity was 84.0 and temperature 67.3 in OR C "the scope room." P3 had a "Colonoscopy, Cold Bx" performed in OR C on 07/05/16.

c. On 07/08/16, the humidity and temperature were not documented on the temperature and humidity log. A line was drawn across the log from 07/06/16 thru 07/10/16 and "AC DOWN NO CASES?" was written across these dates. However, review of perioperative records revealed that P4 had a "Colonoscopy, Anoscopy with EC Snare," P5 had a "Colonoscopy," P6 had an "Esophagogastroduodenoscopy with Cold Biopsy" and P7 had a "Colonoscopy with Hot Biopsy" performed in OR C on 07/08/16.

In an interview on 08/02/16 at 12:50 p.m., S3 was asked about the humidity and temperature not being recorded from 07/06/16 thru 07/10/16. S3 stated, "During that week, I did not chart temperatures and humidity. I was trying to clean up. All of the instruments were contaminated and had to be re-sterilized. S4 and I checked the instruments when condensation was on the walls and floors. We had to wash all the instruments and re-wrap them."

d. On 07/11/16, the humidity was 80.1 and temperature 65.7 in OR C. P8 had an "Esophagogastroduodenoscopy" and "Colonoscopy" performed in OR C on 07/11/16.

e. On 07/12/16, the humidity was 82.5 and temperature 67.3 in OR C. P9 had an "Esophagogastroduodenoscopy," P10 had a "Colonoscopy," P11 had an "Esophagogastroduodenoscopy with Dilation," P2 had a "Colonoscopy" and an "Anal Sphincterotomy," and P13 had a "Colonoscopy" performed in OR C on 07/12/16.

f. On 07/14/16, the humidity was 76.6 and temperature 69.0 in OR C. P14 had a "Colonoscopy," P15 had an "Esophagogastroduodenoscopy," and P16 had a "Colonoscopy with Hot Snare Bx" performed in OR C on 07/14/16.

g. On 07/18/16, the humidity was 74.8 and temperature 65.4 in OR C. P17 had an "Esophagogastroduodenoscopy with Cold Bx," P18 had a "Colonoscopy with Cold Biopsy," P19 had an "Esophagogastroduodenoscopy with Cold Bx" and a "Colonoscopy, " and P20 had an "Esophagogastroduodenoscopy" and a "Colonoscopy" performed in OR C on 07/18/16.

h. On 07/19/16, the humidity was 75.4 and temperature 69.0 in OR B. P21 had a "Laproscopic appendectomy converted to open, umbilical hernia repair with excision of incarcerated pre peritoneal fat," P22 had an "Excision Right Thumb Mass," P23 had a "Laproscopic cholecystectomy with Intra operative Cholangiogram," and P24 had an "Exploratory Laparotomy, Sigmoid Colon Resection with Appendectomy and Colostomy" performed in OR B on 07/19/16.

i. On 07/20/16, the humidity was 76.5 and temperature 67.1 in OR B. P25 had an "Excision Upper Back Mass," P26 had a "Sigmoid Colon Resection with end to end Anastomosis" and "Resection Small Portion of Posterior Wall," P27 had a "Right Lower Abdominal Hernia Repair," and P28 had an "Incision Drainage and Excision Pilonidal Cyst" performed in OR B on 07/20/16.

j. On 07/21/16, the humidity was 73.9 and temperature 64.1 in OR B. P29 had an "Excision of Multiple Scalp Cysts" performed in OR B on 07/21/16.

k. On 07/22/16, the humidity was 77.5 and temperature 66.1 in OR B. P30 had an "Amputation Right 2nd Toe" performed in OR B on 07/22/16.

l. On 07/22/16, the humidity was 77.2 and temperature 66.1 in OR C. P31 had a "Colonoscopy" and P32 had an "Esophagogastroduodenoscopy" performed in OR C on 07/22/16.

m. On 07/25/16, the humidity was 78.9 and temperature 66.6 in OR B. P33 had an "Umbilical Hernia Repair" performed in OR B on 07/25/16.

n. On 07/25/16, the humidity was 78.5 and temperature 66.5 in OR C. P34 had a "Colonoscopy with Cold Bx" and P35 had a "Colonoscopy" performed in OR C on 07/25/16.

o. On 07/26/16, the humidity was 76.8 and temperature 66.0 in OR B. P36 had a "Proctoscopy with dilation of Anorectal Stricture" and P37 had an "Excision Inclusion Cyst Right Upper Back and Skin Tag Left Upper Back" performed in OR B on 07/26/16.

p. On 07/27/16, the humidity was 76.2 and temperature 66.5 in OR B. P38 had a "Hemorrhoidectomy, Sigmoidoscopy," P39 had a "Laproscopic Cholecystectomy," P40 had a "Right Inguinal Hernia Repair," and P41 had a "Laproscopic Appendectomy" performed in OR B on 07/27/16.

q. On 07/28/16, the humidity was 76.1 and temperature 66.8 in OR B. P42 had an "Incision & Drainage Perirectal Abscess" performed in OR B on 07/28/16.

r. On 07/29/16, the humidity was 76.2 and temperature 66.0 in OR B. P43 had a "Laproscopic Cholecystectomy, Adhesiolysis, Intra-operative Cholangiogram" and P44 had an "Exploratory Laparotomy with Adhesiolysis" performed in OR B on 07/29/16.

s. On 08/01/16, the humidity was 74.3 and temperature 64.1 in OR B. P45 had an "Exploratory Laparotomy, Adhesiolysis Dilated Small Bowel Adherence to Left Hemidiaphragm" performed in OR B on 08/01/16.

t. On 08/01/16, the humidity was 72.0 and temperature 67.2 in OR C. P46 had an "Esophagogastroduodenoscopy" and "Colonoscopy with Cold Biopsies" performed in OR C on 08/01/16.

Review of the hospital's operating room policy and procedure identified as "Policy No. 701-T-01" and "Subject: Temperature and Humidity Testing" with an effective date of "3/87" on 08/02/16 at 3:40 p.m. revealed in part the "Temperature is maintained between 68-76 degrees F" and "Humidity is maintained at 55-70%."

Review of the temperature and humidity logs for April, May and June of 2016 on 08/02/16 at 2:50 p.m. revealed the following humidity ranges:

April 2016 humidity - low of 65.9% on 04/04/16 in OR A, B, and C to highs of 80.6% in OR A on 04/29/16, 80.5% in OR B on 04/18/16 and 80.4% on 04/29/16 in OR C

May 2016 humidity - lows of 72% on 05/04/16 in OR A, 71.9% on 05/04/16 in OR B, 71.8% on 05/04/16 in OR C to highs on 05/16/16 of 82.8% in OR A, 82.9% in OR B and 82.5% in OR C

June 2016 humidity - lows of 72.7% on 06/24/16 in OR A, 73.3% on 06/30/16 in OR B, and 72.6% on 06/24/16 in OR C to highs on 06/06/16 of 83.9% in OR A, 84.0% in OR B and 83.8% in OR C.

Review of the operating room (OR) logs for April, May and June of 2016 on 08/02/16 at 3:35 p.m. revealed the following numbers of cases performed:

a. April - 36 cases with 3 performed in OR A, 15 in OR B and 18 in OR C

b. May - 42 cases with 1 performed in OR A, 14 in OR B and 27 in OR C

c. June - 44 cases with 13 performed in OR B and 31 in OR C

In an interview on 08/02/16 at 1:30 p.m., temperature and humidity logs for OR A, OR B and OR C were reviewed with S3 and S3 acknowledged that the humidity was out of range to be maintained according to the hospital ' s policy for the entire months of May, June, July and August and for most of March and April.

In an interview on 08/02/16 at 3:50 p.m., temperature and humidity logs were reviewed with S1 and revealed that the humidity exceeded the required range for the entire months of April, May, June, July and August and exceeded the range to be maintained according to the hospital's own policy and procedure for May, June, July and most of March and April. Review of the operating room log book with S1 on 08/02/16 at 3:50 p.m. revealed that procedures were performed during the months and on dates in which humidity exceeded the required range and the range to be maintained according to the hospital's policy and procedure. S1 confirmed the above findings and stated, "I didn ' t know they were out of range before we had the problem with the chillers."

Based on record review and interview, the hospital did not meet the requirement in that a consistent problem with humidity in the operating rooms was not identified for at least three months placing all patients that underwent procedures at risk for infection.
Findings Include:
Review of the temperature and humidity logs for April, May, June, July and August of 2016 on 08/02/16 at 2:50 p.m. revealed the following humidity ranges:
· April 2016 humidity - low of 65.9% on 04/04/16 in OR A, B, and C to highs of 80.6% in OR A on 04/29/16, 80.5% in OR B on 04/18/16 and 80.4% on 04/29/16 in OR C
· May 2016 humidity - lows of 72% on 05/04/16 in OR A, 71.9% on 05/04/16 in OR B, 71.8% on 05/04/16 in OR C to highs on 05/16/16 of 82.8% in OR A, 82.9% in OR B and 82.5% in OR C
· June 2016 humidity - lows of 72.7% on 06/24/16 in OR A, 73.3% on 06/30/16 in OR B, and 72.6% on 06/24/16 in OR C to highs on 06/06/16 of 83.9% in OR A, 84.0% in OR B and 83.8% in OR C.
· July 2016 humidity - lows of 71.4% on 07/19/16 in OR A, 73% on 07/18/16 in OR B and 73.6% on 07/19/16 in OR C to highs of 83.9% in OR A on 07/05/16, 84% in OR B on 07/05/16 and 07/12/16 and 84% in OR C on 07/05/16.

· August 2016 humidity - lows of 73.6%, 74.3% in OR B and 72% in OR C on 08/01/16 to highs on 08/02/16 of 82.4% in OR A, 82.7% in OR B and 79% in OR C.

Review of the operating room (OR) logs for April, May and June of 2016 on 08/02/16 at 3:35 p.m. revealed the following numbers of cases performed:
· April - 36 cases with 3 performed in OR A, 15 in OR B and 18 in OR C
· May - 42 cases with 1 performed in OR A, 14 in OR B and 27 in OR C
· June - 44 cases with 13 performed in OR B and 31 in OR C
In an interview on 08/02/16 at 3:50 p.m., temperature and humidity logs were reviewed with S1 and revealed that the humidity exceeded the required range for the entire months of April, May, June, July and August and exceeded the range to be maintained according to the hospital ' s own policy and procedure for May, June, July and most of March and April. Review of the operating room log book with S1 on 08/02/16 at 3:50 p.m. revealed that procedures were performed during the months and on dates in which humidity exceeded the required range and the range to be maintained according to the hospital ' s policy and procedure. S1 confirmed the above findings and stated, " I didn ' t know they were out of range before we had the problem with the chillers. "

Based on observations, interviews, and record reviews, the hospital performed procedures in operating rooms where the humidity and temperature were not maintained in accordance with nationally accepted standards of practice. The American Society for Heating, Refrigeration, and Air conditioning Engineers (ASHRAE) Standard 170, Ventilation of Health Care Facilities Addendum D requires relative humidity in operating rooms to be maintained between 20-60 percent. The acceptable standard for operating room temperature is between 68° and 75° F as recommended by the Association of periOperative Registered Nurses (AORN). Excessive humidity is conducive to microbial growth and placed the patients undergoing procedures in these operating rooms at risk for infections affecting the quality of care provided.

During a tour of the three operating rooms accompanied by S3 on 08/02/16 beginning at 12:37 p.m. observations revealed the following:

a. At 12:37 p.m., the wall hygrometer and temperature indicator read 91% humidity and 70 degrees F in surgical room A referred to as "OR A" by S3 who stated "A is down and not used." The humidity and temperature taken by S3 with a Digital Thermo/Hygrometer read 81% and 72 F. S3 stated that, "I've been using the Digital Thermometer and Hygrometer since January to take the readings because I want accurate readings" and confirmed the humidity and temperature logs reflect these readings.

b. At 12:43 p.m., the wall hygrometer and temperature indicator read 86% humidity and 70 degrees F in surgical room B referred to as "OR B" by S3 who stated, "B is used for 99% of general surgery cases and laparoscopic surgery." The humidity and temperature taken by S3 with a Digital Thermo/Hygrometer read 76.7% and 72.9 F.

c. At 12:46 p.m., the wall hygrometer and temperature indicator read 79% humidity and 76 degrees F in the Minor Surgery room referred to as "OR C or the scope room" by S3. The humidity and temperature taken by S3 with a Digital Thermo/Hygrometer read 67.2% and 78.5 F. The Minor Surgery room or "scope room" had two doors and one door remained open to the corridor. When asked about the door being left open to the corridor, S3 stated, "It is left open to attempt to keep the room at a more controlled temperature than it would be if it were closed." A Frigidaire dehumidifier was observed sitting on a rolling cart in front of an endoscope hanging on the wall. A black hose was connected to the dehumidifier and the other end of the hose rested in clear liquid at the bottom of an open gray plastic four sided container. When asked about the dehumidifier, S3 stated, "At some point during the 14th to 18th of July we got de-humidifiers for each room and ran them between cases if applicable. It keeps the condensation down. The catch basket is emptied each morning and on the week-end the house supervisor is doing it. At some point roughly between July 18th and 25th room B got to a point where we felt it didn ' t need a dehumidifier so we took it out."

d. During a tour of the instrument room accompanied by S3 on 08/02/16 at 1:30 p.m., the humidity and temperature taken by S3 with a Digital Thermo/Hygrometer read 51.2% and 77.2 F.

e. During a tour of the sterile processing room accompanied by S3 on 08/02/16 at 1:58 p.m., the wall hygrometer and temperature indicator read 85% humidity and 70 degrees F. The humidity and temperature taken by S3 with a Digital Thermo/Hygrometer read 64% and 72 F.

In interviews on 08/02/16, at 12:46 p.m., 1:30 p.m. and 1:58 p.m., S3 confirmed the above findings.

Review of the hospital's temperature and humidity log on 08/02/16 at 12:48 p.m. for 08/02/16 revealed that the humidity was 82.4% in A, 82.7% in B and 79.0% in C. The temperature was 68.4 degrees F in A, 67.9 degrees F in B and 71.1 F degrees in C.

Review of a handwritten list dated 07/13/16 that was provided on 08/02/16 by S3 and identified by S3 as lab results of "swabs taken of vents all over the department" revealed the following: "Pre-op - Growth" and "Ster. Hallway - growth."

Review of the hospital's perioperative records, temperature and humidity logs on 08/02/16 at 3:30 p.m. for the time period from 07/01/16 to 08/02/16 specifically revealed the following on days in which procedures were performed:

a. On 07/01/16 the humidity was 74.1 and temperature 65.9 in OR B. P1 had a "Left Above Knee Stump Revision," and P2 had an "Excision of Mass Right Forearm, Mass Left Lower Back, Melanotic Nevus Left Upper Back" performed in OR B on 07/01/16.

b. On 07/05/16, the humidity was 84.0 and temperature 67.3 in OR C "the scope room." P3 had a "Colonoscopy, Cold Bx" performed in OR C on 07/05/16.

c. On 07/08/16, the humidity and temperature were not documented on the temperature and humidity log. A line was drawn across the log from 07/06/16 thru 07/10/16 and "AC DOWN NO CASES?" was written across these dates. However, review of perioperative records revealed that P4 had a "Colonoscopy, Anoscopy with EC Snare," P5 had a "Colonoscopy," P6 had an "Esophagogastroduodenoscopy with Cold Biopsy" and P7 had a "Colonoscopy with Hot Biopsy" performed in OR C on 07/08/16.

In an interview on 08/02/16, at 12:50 p.m., S3 was asked about the humidity and temperature not being recorded from 07/06/16 thru 07/10/16. S3 stated, "During that week, I did not chart temperatures and humidity. I was trying to clean up. All of the instruments were contaminated and had to be re-sterilized. S4 and I checked the instruments when condensation was on the walls and floors. We had to wash all the instruments and re-wrap them."

d. On 07/11/16, the humidity was 80.1 and temperature 65.7 in OR C. P8 had an "Esophagogastroduodenoscopy" and "Colonoscopy" performed in OR C on 07/11/16.

e. On 07/12/16, the humidity was 82.5 and temperature 67.3 in OR C. P9 had an "Esophagogastroduodenoscopy," P10 had a "Colonoscopy," P11 had an "Esophagogastroduodenoscopy with Dilation," P2 had a "Colonoscopy" and an "Anal Sphincterotomy," and P13 had a "Colonoscopy" performed in OR C on 07/12/16.

f. On 07/14/16, the humidity was 76.6 and temperature 69.0 in OR C. P14 had a "Colonoscopy," P15 had an "Esophagogastroduodenoscopy," and P16 had a "Colonoscopy with Hot Snare Bx" performed in OR C on 07/14/16.

g. On 07/18/16, the humidity was 74.8 and temperature 65.4 in OR C. P17 had an "Esophagogastroduodenoscopy with Cold Bx," P18 had a "Colonoscopy with Cold Biopsy," P19 had an "Esophagogastroduodenoscopy with Cold Bx" and a "Colonoscopy," and P20 had an "Esophagogastroduodenoscopy" and a "Colonoscopy" performed in OR C on 07/18/16.

h. On 07/19/16, the humidity was 75.4 and temperature 69.0 in OR B. P21 had a "Laproscopic appendectomy converted to open, umbilical hernia repair with excision of incarcerated pre peritoneal fat," P22 had an "Excision Right Thumb Mass," P23 had a "Laproscopic cholecystectomy with Intra operative Cholangiogram," and P24 had an "Exploratory Laparotomy, Sigmoid Colon Resection with Appendectomy and Colostomy" performed in OR B on 07/19/16.

i. On 07/20/16, the humidity was 76.5 and temperature 67.1 in OR B. P25 had an "Excision Upper Back Mass," P26 had a "Sigmoid Colon Resection with end to end Anastomosis" and "Resection Small Portion of Posterior ? Wall," P27 had a "Right Lower Abdominal Hernia Repair," and P28 had an "Incision Drainage and Excision Pilonidal Cyst" performed in OR B on 07/20/16.

j. On 07/21/16, the humidity was 73.9 and temperature 64.1 in OR B. P29 had an "Excision of Multiple Scalp Cysts" performed in OR B on 07/21/16.

k. On 07/22/16, the humidity was 77.5 and temperature 66.1 in OR B. P30 had an "Amputation Right 2nd Toe" performed in OR B on 07/22/16.

l. On 07/22/16, the humidity was 77.2 and temperature 66.1 in OR C. P31 had a "Colonoscopy" and P32 had an "Esophagogastroduodenoscopy" performed in OR C on 07/22/16.

m. On 07/25/16, the humidity was 78.9 and temperature 66.6 in OR B. P33 had an "Umbilical Hernia Repair" performed in OR B on 07/25/16.

n. On 07/25/16, the humidity was 78.5 and temperature 66.5 in OR C. P34 had a "Colonoscopy with Cold Bx" and P35 had a "Colonoscopy" performed in OR C on 07/25/16.

o. On 07/26/16, the humidity was 76.8 and temperature 66.0 in OR B. P36 had a "Proctoscopy with dilation of Anorectal Stricture" and P37 had an "Excision Inclusion Cyst Right Upper Back and Skin Tag Left Upper Back" performed in OR B on 07/26/16.

p. On 07/27/16, the humidity was 76.2 and temperature 66.5 in OR B. P38 had a "Hemorrhoidectomy, Sigmoidoscopy," P39 had a "Laproscopic Cholecystectomy," P40 had a "Right Inguinal Hernia Repair," and P41 had a "Laproscopic Appendectomy" performed in OR B on 07/27/16.

q. On 07/28/16, the humidity was 76.1 and temperature 66.8 in OR B. P42 had an "Incision & Drainage Perirectal Abscess" performed in OR B on 07/28/16.

r. On 07/29/16, the humidity was 76.2 and temperature 66.0 in OR B. P43 had a "Laproscopic Cholecystectomy, Adhesiolysis, Intra-operative Cholangiogram" and P44 had an "Exploratory Laparotomy with Adhesiolysis" performed in OR B on 07/29/16.

s. On 08/01/16, the humidity was 74.3 and temperature 64.1 in OR B. P45 had an "Exploratory Laparotomy, Adhesiolysis Dilated Small Bowel Adherence to Left Hemidiaphragm" performed in OR B on 08/01/16.

t. On 08/01/16, the humidity was 72.0 and temperature 67.2 in OR C. P46 had an "Esophagogastroduodenoscopy" and "Colonoscopy with Cold Biopsies" performed in OR C on 08/01/16.

Review of the hospital's operating room policy and procedure identified as "Policy No. 701-T-01" and "Subject: Temperature and Humidity Testing" with an effective date of "3/87" on 08/02/16 at 3:40 p.m. revealed in part the "Temperature is maintained between 68-76 degrees F" and "Humidity is maintained at 55-70%."

Review of the temperature and humidity logs for April, May and June of 2016 on 08/02/16 at 2:50 p.m. revealed the following humidity ranges:

April 2016 humidity - low of 65.9% on 04/04/16 in OR A, B, and C to highs of 80.6% in OR A on 04/29/16, 80.5% in OR B on 04/18/16 and 80.4% on 04/29/16 in OR C

May 2016 humidity - lows of 72% on 05/04/16 in OR A, 71.9% on 05/04/16 in OR B, 71.8% on 05/04/16 in OR C to highs on 05/16/16 of 82.8% in OR A, 82.9% in OR B and 82.5% in OR C

June 2016 humidity - lows of 72.7% on 06/24/16 in OR A, 73.3% on 06/30/16 in OR B, and 72.6% on 06/24/16 in OR C to highs on 06/06/16 of 83.9% in OR A, 84.0% in OR B and 83.8% in OR C.

Review of the operating room (OR) logs for April, May and June of 2016 on 08/02/16 at 3:35 p.m. revealed the following numbers of cases performed:

a. April - 36 cases with 3 performed in OR A, 15 in OR B and 18 in OR C

b. May - 42 cases with 1 performed in OR A, 14 in OR B and 27 in OR C

c. June - 44 cases with 13 performed in OR B and 31 in OR C

In an interview on 08/02/16, at 1:30 p.m., temperature and humidity logs for OR A, OR B and OR C were reviewed with S3 and S3 acknowledged that the humidity was out of range to be maintained according to the hospital ' s policy for the entire months of May, June, July and August and for most of March and April.

In an interview on 08/02/16, at 3:50 p.m., temperature and humidity logs were reviewed with S1 and revealed that the humidity exceeded the required range for the entire months of April, May, June, July and August and exceeded the range to be maintained according to the hospital's own policy and procedure for May, June, July and most of March and April. Review of the operating room log book with S1 on 08/02/16 at 3:50 p.m. revealed that procedures were performed during the months and on dates in which humidity exceeded the required range and the range to be maintained according to the hospital ' s policy and procedure. S1 confirmed the above findings and stated, "I didn't know they were out of range before we had the problem with the chillers."

Based on observation, record review, and interview, the hospital failed to have a policy governing surgical care to assure the achievement and maintenance of high standards of medical practice and patient care because the hospital's policy to maintain humidity in the operating room at 55-70% and temperature at 68-76 degrees Fahrenheit were not within acceptable parameters. The American Society for Heating, Refrigeration, and Air conditioning Engineers (ASHRAE) Standard 170, Ventilation of Health Care Facilities Addendum D requires relative humidity in operating rooms to be maintained between 20-60 percent. The acceptable standard for operating room temperature is between 68° and 75° F as recommended by the Association of periOperative Registered Nurses (AORN). Excessive humidity is conducive to microbial growth and placed the patients undergoing procedures in these operating rooms at risk for infections affecting the quality of care provided.


Findings include:


Observations of the hospital's three operating rooms on 08/02/16 beginning at 12:37 p.m. revealed the following:


· At 12:37 p.m. in OR A - the humidity and temperature taken by S3 with a Digital Thermo/Hygrometer read 81% and 72 F.


· At 12:43 p.m. in OR B - the humidity and temperature taken by S3 with a Digital Thermo/Hygrometer read 76.7% and 72.9 F.

· At 12:46 p.m., in OR C - the humidity and temperature taken by S3 with a Digital Thermo/Hygrometer read 67.2% and 78.5 F. The Minor Surgery room or "scope room" had two doors and one door remained open to the corridor. When asked about the door being left open to the corridor, S3 stated, " It is left open to attempt to keep the room at a more controlled temperature than it would be if it were closed." A Frigidaire dehumidifier was observed sitting on a rolling cart in front of an endoscope hanging on the wall. A black hose was connected to the dehumidifier and the other end of the hose rested in clear liquid at the bottom of an open gray plastic four sided container. When asked about the dehumidifier, S3 stated, "At some point during the 14th to 18th of July we got de-humidifiers for each room and ran them between cases if applicable. It keeps the condensation down. The catch basket is emptied each morning and on the week-end the house supervisor is doing it. At some point roughly between July 18th and 25th room B got to a point where we felt it didn ' t need a dehumidifier so we took it out."

· At 1:30 p.m. in the instrument room - the humidity and temperature taken by S3 with a Digital Thermo/Hygrometer read 51.2% and 77.2 F.

· At 1:58 p.m. in the sterile processing room - the humidity and temperature taken by S3 with a Digital Thermo/Hygrometer read 64% and 72 F.

In interviews on 08/02/16, at 12:46 p.m., 1:30 p.m. and 1:58 p.m., S3 confirmed the above findings.

Review of the temperature and humidity logs for April, May, June, July and August of 2016 on 08/02/16 at 2:50 p.m. revealed the following humidity ranges:

April 2016 humidity - low of 65.9% on 04/04/16 in OR A, B, and C to highs of 80.6% in OR A on 04/29/16, 80.5% in OR B on 04/18/16 and 80.4% on 04/29/16 in OR C

May 2016 humidity - lows of 72% on 05/04/16 in OR A, 71.9% on 05/04/16 in OR B, 71.8% on 05/04/16 in OR C to highs on 05/16/16 of 82.8% in OR A, 82.9% in OR B and 82.5% in OR C

June 2016 humidity - lows of 72.7% on 06/24/16 in OR A, 73.3% on 06/30/16 in OR B, and 72.6% on 06/24/16 in OR C to highs on 06/06/16 of 83.9% in OR A, 84.0% in OR B and 83.8% in OR C.

July 2016 humidity - lows of 71.4% on 07/19/16 in OR A, 73% on 07/18/16 in OR B and 73.6% on 07/19/16 in OR C to highs of 83.9% in OR A on 07/05/16, 84% in OR B on 07/05/16 and 07/12/16 and 84% in OR C on 07/05/16.


August 2016 humidity - lows of 73.6%, 74.3% in OR B and 72% in OR C on 08/01/16 to highs on 08/02/16 of 82.4% in OR A, 82.7% in OR B and 79% in OR C.


Review of the hospital ' s operating room policy and procedure identified as "Policy No. 701-T-01" and "Subject: Temperature and Humidity Testing" with an effective date of "3/87" on 08/02/16 at 3:40 p.m. revealed in part the "Temperature is maintained between 68-76 degrees F" and "Humidity is maintained at 55-70%."

In an interview on 08/02/16, at 1:30 p.m., temperature and humidity logs for OR A, OR B and OR C were reviewed with S3 and S3 acknowledged that the humidity was out of range to be maintained according to the hospital's policy for the entire months of May, June, July and August and for most of March and April.

In an interview on 08/02/16, at 3:50 p.m., temperature and humidity logs were reviewed with S1 and revealed that the humidity exceeded the required range for the entire months of April, May, June, July and August and exceeded the range to be maintained according to the hospital ' s own policy and procedure for May, June, July and most of March and April.

Based on record review and interview, the hospital did not meet the requirement in that the operating room register was not complete and up to date for the 30 procedures performed between 07/18/16 and 08/01/16.

Findings Include:

Review on 08/02/16 of the operative log book from January 1, 2016 thru July 2016 revealed that the operative log book had no entries after 07/14/16, was not complete and up to date after 07/14/16.

During an interview on 08/02/16 at 12:08 p.m., S2 confirmed the operative log book was not complete and was not up to date and stated she was " working on it. " On 08/02/16 at 3:30 p.m. after request, S2 provided copies of perioperative records for patients that had the 30 procedures performed between 07/28/26 and 08/01/16 that were not on the operative log book.