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Based on observation, interview, and record review, the hospital failed to ensure the temperature level was maintained the SPD Decontamination room on 9/10/24. This failure had the potential to result in poor health outcomes to the patients.

Findings:

Review of the hospital's P&P titled Temperature and Humidity Levels: ICU, NICU, Nursery, Delivery Rooms and Operating Rooms dated 9/27/23, showed the following:

* The responsibility of the Engineering Department is to ensure that the temperature and humidity levels are maintained within the appropriate range.

* The temperatures will be maintained between 60 to 73 degrees Fahrenheit for the Sterile Processing Decontamination room.

* Clinical designee or designee will check and document the temperature and humidity levels every morning prior to beginning of the shifts in the temperature and humidity logs for that area.

* If the temperature and /or humidity levels are observed to be out of range, the following process will be followed:

- If the variance is observed, the clinical personnel will notify/call engineering and follow up every 15 minutes for a response.

- Once the temperature and humidity levels are brought back in range, the adjusted temperature and humidity levels will be documented on the log indicating the time of the resolution.

On 9/10/24 at 1257 hours, a tour of the SPD decontamination area was conducted with the Sterile Technician.

The temperature monitor for the SPD decontamination area was observed. The temperature level was 74.4 degrees Fahrenheit which was out of range and the humidity level was 58.4%.

On 9/10/24 at 1316 hours, a tour of the SPD department was conducted with the Quality Director, Director of Surgical Services, Sterile Processing Supervisor, and Sterile Technician. At 1316 hours, the temperature level of the SPD decontamination was 75 degrees Fahrenheit which was out of range and the humidity level was 57.8%.

Review of the Daily Temperature and Humidity Log SPD Decontam (Decontamination) for September 2024 showed the acceptable temperature range was 60 to 65 degrees Fahrenheit and the acceptable humidity range was 20 to 60%. The log also showed the staff had performed the temperature and humidity checks daily from 9/1 - 9/9/24, and the temperature and humidity levels were documented as within the acceptable range.

However, review of the Daily Temperature and Humidity Log SPD Decontam for September 2024 showed the temperature and humidity levels for 9/10/24 was left blank.

The Sterile Technician was asked if the room needed to be on a controlled temperature. The Sterile Technician stated yes, the temperature levels should be around 60 to 65 degrees Fahrenheit and the humidity levels should be 20% and maximum of 60%. When asked if the temperature levels were within the acceptable range, the Sterile Technician stated no. When asked what he needed to do if the temperature levels were out of range, the Sterile Technician stated he usually called the engineering staff for out of range. When asked about the frequency of checking the temperature levels, the Sterile Technician stated every day, no specific hours, and usually in the morning when the Sterile Technician started the shifts. When asked if there was any documented temperature levels of the SPD Decontamination room on 9/10/24, the Sterile Technician stated no, the Sterile Technician forgot to document today, 9/10/24, because the Sterile Technician was busy.

The Sterile Technician provided an additional copy Daily Temperature and Humidity Log SPD Decontam for September 2024, which showed on 9/10/24, the temperature was 74 degrees Fahrenheit and the humidity level was 51%.

A follow- up interview was conducted with the Quality Director, Director of Surgical Services, Sterile Processing Supervisor, and Sterile Technician. When asked if the temperature was within the normal range, the Director of Surgical Services stated no, but the humidity level was within the normal range. When asked about the intervention when the temperature level was out of range, the Director of Surgical Services stated the staff would call the engineering staff. When asked when the staff needed to document in the log, the Sterile Technician stated just now. The Sterile Processing Supervisor also stated the Sterile Processing Supervisor did not know why the temperature was not checked in the morning. When asked how they knew if the room temperature was within the normal range since this morning. The Sterile Technician stated the Sterile Technician could feel the temperature and usually call the engineering staff to fix it. The Sterile Technician further stated he did not know the temperature in the morning because he was doing something else. The hosptial's adminstration staff was informed and acknowledged the findings.