HospitalInspections.org

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

The findings were:

482.12 Tag A-0083

The information reviewed during the survey provided evidence the facility failed to notify the Department of Health Division of Acute and Ambulatory Care [Department] of elevated humidity readings in the dental surgery clinic and ophthalmology clinic procedure rooms located in the facility's Hospital Outpatient (HOP) clinics at 675 Baltimore Drive, Wilkes-Barre and the General Surgery clinic and Plastic surgery clinic procedure rooms located at the HOP clinics at the Valley Medical Building located at 1000 East Mountain Boulevard, Wilkes-Barre and it was determined the operating practitioner failed to document awareness of elevated humidity readings and to determine proceeding with or canceling the surgical procedure.

A discussion took place with the survey team and the facility's administrative staff (EMP1, EMP2, EMP3, EMP4, EMP5 and EMP6) regarding the survey team's concerns related to Governing body on August 31, 2021 at approximately 1:00 PM.


Cross reference
482.12(e) Contracted Services

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to notify the Department of Health Division of Acute and Ambulatory Care [Department] of elevated humidity readings in the dental surgery clinic and ophthalmology clinic procedure rooms located in the facility's Hospital Outpatient (HOP) clinics at 675 Baltimore Drive, Wilkes-Barre and the General Surgery clinic and Plastic surgery clinic procedure rooms located at the HOP clinics at the Valley Medical Building located at 1000 East Mountain Boulevard, Wilkes-Barre.

Findings include:

Review on August 27, 2021, of the facility's "Geisinger Wyoming Valley Medical Center (GWV) Patient Safety Program and Plan" no review date, revealed "Purpose Overview and Purpose" Geisinger Wyoming Valley Medical Center (GWV) is dedicated to creating, supporting and disseminating a culture of safety throughout the organization. Continual focus on, and improvement of patient safety is inherent to our mission of enhancing the quality of life for those we serve. Awareness of our processes and systems of care, including potential and actual failures of these systems that compromise patient safety is integral in our efforts to improve ...GWV leadership, medical staff, managers, and employees must actively support the patient safety improvement and management program in order to achieve our goals. The purpose of the patient safety plan is to provide a framework for the implementation of various components of the patient safety program at GWV...Policy GWV's patient safety plan is based on the following principles: Commitment and engagement of the governing body and executive leadership. Responsibility and accountability of physicians, management and staff ...Compliance with regulatory and accreditation requirements. Management of Patient Safety Events and Reporting Identification and reporting of events and near miss events is fundamental to the effectiveness of the Patient Safety Program and Plan ..."

Review on August 27, 2021, of the facility's "Identification of Events and Patient Safety Reporting" policy, no review date, revealed "Purpose This Patient Safety Reporting procedure establishes guidelines to: Report Patient Safety Events as required by Pennsylvania Act 13. Providing a safe environment. Mitigating the risk of an accident. To educate and encourage staff to identify and report incidents, adverse event or near misses without the fear of reprisal. Establish a reporting system to notify responsible parties about incidents, adverse event or near misses and allow prompt investigation of incidents. Comply with external regulatory and statutory requirements for incidents and infrastructure events ...Definitions ...Infrastructure Failures - An undesirable or unintended event, occurrence or situation involving the infrastructure of a medical facility ...Policy The policy of Patient Safety Reporting is to promote a culture of safety across the organization. It is our belief that in most cases errors and adverse events are the result of system failures or unsafe behavioral choices and not the result of intentional reckless behavior by caregivers. The reporting, tracking, and evaluation of reported errors and adverse events provides us the opportunity to evaluate and improve our systems and coach employees to make safer choices and therefore enhance patient safety. All employees are required to report patient safety events, adverse events and near miss events via the available reporting mechanisms. This encompasses the reporting of incidents, adverse, serious and sentinel events and infrastructure failures as defined and required by state and federal law or other licensing or accreditation bodies. All employees and medical staff are required to report any event, condition, or situation that compromises patient safety or the quality of patient care to their immediate supervisor and to the facility or system Patient Safety Officer ..."

Review on August 27, 2021, of the facility's "Temperature and Humidity Control" policy, last approved May 5, 2021, revealed "Purpose To maintain the temperature and humidity in the ...Procedure rooms for the benefit of the patient and to maintain sterility of supplies ...Policy 1. The following area will maintain the temperature and humidity within the acceptable ranges. Procedure rooms ...Humidity range 30 - 60 [percent]..."

Dental Surgery Clinic located at 675 Baltimore Drive:

A request was made of EMP1, EMP2 and EMP6 for the temperature and humidity logs for procedure rooms 5 and 6 from June 2021 through August 27, 2021. None were provided.

Interview with EMP6 on August 27, 2021, at approximately 11:00 a.m. revealed this employee was not able to provide a temperature and humidity monitoring report for room 5. EMP6 revealed there is no temperature and humidity monitoring device in procedure room 5. EMP6 also revealed there is no humidity monitoring report for room 6.

1. Review on August 27, 2021, of the facility provided humidity logs revealed days procedure room 1's max A.M. humidity readings were greater than 60 percent on June 3, 5, 12 and 19, 2021; July 5, 6, 22, 23 and 24, 2021 and August 1, 2, 4, 5, 6, 12 and 15, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 1's max A.M. humidity readings were greater than 70 percent on June 4, 6, 7, 8, 10, 13, 14, 15, 21, 22, 26, 27, 28 and 29, 2021; July 3, 6, 8, 10, 11, 13, 15, 16, 19, 20, 21, 25, 26, 27, 28, 29 and 30, 2021 and August 7, 8, 9, 10, 13, 16, 17 and 19, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 1's max A.M. humidity readings were greater than 80 percent on June 9, 20 and 30, 2021; July 1, 2, 7, 9, 12, 14, 17 and 18, 2021 and August 11, 14, 18, 20, 21, 22, 23, 24, 25 and 26, 2021.

Interview with EMP1, EMP2, EMP3, EMP4 and EMP6 on August 27, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room 1 for June 1 through August 31, 2021. EMP1, EMP2, EMP3, EMP4 and EMP6 confirmed the procedure room 1's humidity readings were considered out of range.

2. Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 2's max A.M. humidity readings were greater than 60 percent on June 12 and 24, 2021; July 22, 23 and 24, 2021 and August 1, 2, 3 and 5, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 2's max A.M. humidity readings were greater than 70 percent June 3, 4, 5, 6, 7, 13, 15, 19, 20, 22 and 26, 2021; July 3, 4, 5, 6, 8, 11, 15, 21, 27, 28 and 29, 2021 and August 4, 6, 9 and 15, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 2's max A.M. humidity readings were greater than 80 percent on June 8, 9, 10, 14, 21, 27, 28, 29, 30 and 31, 2021; July 1, 2, 7, 9, 10, 12, 13, 14, 16, 17, 18, 19, 20, 25, 26 and 30, 2021 and August 7, 8, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 and 26, 2021.

Interview with EMP1, EMP2, EMP3, EMP4 and EMP6 on August 27, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room 2 for June 1 through August 31, 2021. EMP1, EMP2, EMP3, EMP4 and EMP6 confirmed the procedure room 2's humidity readings were considered out of range.

3. Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 3's max A.M. humidity readings were greater than 60 percent on June 11, 12, 16 and 24, 2021; July 23 and 24, 2021 and August 1, 2, 3, 4 and 5, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 3's max A.M. humidity readings were greater than 70 percent on June 3, 4, 5, 6, 7, 13, 15, 19, 20, 22, 26, 28 and 29, 2021; July 3, 4, 5, 6, 8, 11, 15, 21, 22, 26, 27, 28, 29 and 30, 2021 and August 6, 7, 8, 9, 13 and 15, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 3's max A.M. humidity readings were greater than 80 percent on June 8, 9, 10, 14, 21, 27 and 30, 2021; July 1, 2, 7, 9, 10, 12, 13, 14, 16, 17, 18, 19, 21 and 25, 2021 and August 10, 11, 12, 14, 16, 17,18, 19, 20, 21, 22, 23, 24, 25 and 26, 2021.

Interview with EMP1, EMP2, EMP3, EMP4 and EMP6 on August 27, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room 3 for June 1 through August 31, 2021. EMP1, EMP2, EMP3, EMP4 and EMP6 confirmed the procedure room 3's humidity readings were considered out of range.

4. Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 4's max A.M. humidity readings were greater than 60 percent on June 11, 12, 16 and 23, 2021; July 23, 2021 and August 1, 3 and 5, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 4's max A.M. humidity readings were greater than 70 percent on June 3, 4, 5, 6, 13, 15, 19, 20 and 22, 2021; July 3, 4, 5, 6, 21, 22, 24 and 27, 2021 and August 2, 4, 6, 9 and 15, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 4's max A.M. humidity readings were greater than 80 percent on June 7, 8, 9, 10, 14, 21, 26, 27, 28, 29 and 30, 2021 ; July 1, 2, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 25, 26, 28, 29 and 30, 2021 and August 7, 8, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 25 and 26, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 4's max A.M. humidity readings were greater than 90 percent on August 24, 2021.

Interview with EMP1, EMP2, EMP3, EMP4 and EMP6 on August 27, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room 4 for June 1 through August 31, 2021. EMP1, EMP2, EMP3, EMP4 and EMP6 confirmed the procedure room 4's humidity level s were considered out of range.

Interview with EMP1, EMP3 and EMP4 on August 27, 2021, at the time of review, confirmed these out-of-range humidity readings met the criteria of an infrastructure failure and the facility did not submit an infrastructure failure event to the Department and the Patient Safety Authority within 24 hours of occurrence.

Ophthalmology Clinic located at 675 Baltimore Drive:

1. Review on September 2, 2021, of the facility provided humidity logs revealed days procedure room 1's max A.M. humidity readings were greater than 60 percent on June 1, 3, 7, 8, 9, 10, 14, 15, 17, 18, 19, 21, 22, 23, 24, 26, 27, 28, 29 and 30, 2021; July 1, 4 through 10, 2021; July 5 through 10, 2021; July 12 through 31, 2021 and August 2 through 5, 2021; August 7 through 27, 2021 and August 29 and 30, 2021.

Interview with EMP1, EMP3, EMP4 and EMP14 on September 2, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room 1 for June 1 through August 31, 2021. EMP1, EMP3, EMP4 and EMP14 confirmed the procedure room 1's humidity readings were considered out of range.

2. Review on September 2, 2021, of the facility provided humidity logs revealed procedure room 1's max A.M. humidity readings were greater than 70 percent on June 2, 4, 5, 6, 11, 12, 13, 16, 20, and 25, 2021; July 2, 3 and 11, 2021 and August 1, 6, 28 and 31, 2021.

Interview with EMP1, EMP3, EMP4 and EMP14 on September 2, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room 2 for June 1 through August 31, 2021. EMP1, EMP3, EMP4 and EMP14 confirmed the procedure room 1's humidity readings were considered out of range.

Interview with EMP1, EMP3 and EMP4 on September 2, 2021, at the time of review, confirmed these out-of-range humidity readings met the criteria of an infrastructure failure and the facility did not submit an infrastructure failure event to the Department and the Patient Safety Authority within 24 hours of occurrence.

Plastic Surgery located at Valley Medical Building:

1. Review on September 2, 2021, of the facility provided humidity logs revealed days procedure room A's max A.M. humidity readings were greater than 60 percent on June 2, 3,12 and 16, 2021; July 3, 4, 5 and 23, 2021 and August 3 and 5, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room A's max A.M. humidity readings were greater than 70 percent on June 4, 5, 6, 7, 13, 14, 15, 19, 20, 22, 26 and 27, 2021; July 22, 24, 25, 27 and 29, 2021 and August 1, 2, 4, 6, 7, 8, 9, 16, 17, 28, 29, 30 and 31, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room A's max A.M. humidity readings were greater than 80 percent on June 8, 9, 10, 21, 28, 29 and 30, 2021; July 1 and 2, 2021; July 6 through 21, 2021; July 26 and 30, 2021 and August 10 through 14, 2021; August 18 through 27, 2021.

Interview with EMP1, EMP3, EMP4 and EMP15 on September 2, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room A for June 1 through August 31, 2021. EMP1, EMP3, EMP4 and EMP15 confirmed the procedure room A's humidity readings were considered out of range.

2. Review on September 2, 2021, of the facility provided humidity logs revealed days procedure room B's max A.M. humidity readings were greater than 60 percent on June 23, 24 and 31 2021; and August 3, 4 and 31, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room B's max A.M. humidity readings were greater than 70 percent on June 19 and 22, 2021; July 3, 4, 5, 22, 23 and 24, 2021 and August 1, 2, 5, 6, 15, 16, 28, 29 and 30, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room B's max A.M. humidity readings were greater than 80 percent on June 20, 21, 26, 27, 28, 29, 30, 2021; July 1 and 2, 2021; July 6 through 21, 2021; and July 25 through 30, 2021 and August 7 through 14, 2021; August 17 through 27, 2021.

Interview with EMP1, EMP3, EMP4 and EMP15 on September 2, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room B for June 1 through August 31, 2021. EMP1, EMP3, EMP4 and EMP15 confirmed the procedure room B's humidity readings were considered out of range.

3. Review on September 2, 2021, of the facility provided humidity logs revealed days procedure room C's max A.M. humidity readings were greater than 60 percent on June 2 and 16, 2021 and August 3, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room C's max A.M. humidity readings were greater than 70 percent on June 3, 5, 12, 15 and 22, 2021; July 4, 5, 22, 23 and 24, 2021 and August 1, 2, 4, 5, 6, 15, 16, 29, 30 and 31, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room C's max A.M. humidity readings were greater than 80 percent on June 4, 6, 7, 8, 10, 13, 14, 19, 20, 21, 26, 27, 28 and 30, 2021; July 1, 2 and 3, 2021, July 6 through 11, 2021, July 15 through 21, 2021 and July 25 through 30, 2021 and August 7, 8, 9, 14, 17, 20, 21, 22, 25, 26, 27 and 28, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room C's max A.M. humidity readings were greater than 90 percent on June 9 and 29, 2021; July 12, 13 and 14, 2021 and August 10, 11, 12, 13, 18, 19, 23 and 24, 2021.

Interview with EMP1, EMP3, EMP4 and EMP15 on September 2, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room C for June 1 through August 31, 2021. EMP1, EMP3, EMP4 and EMP15 confirmed the procedure room C's humidity readings were considered out of range.

Interview with EMP1, EMP3 and EMP4 on September 2, 2021, at the time of review, confirmed these out-of-range humidity readings met the criteria of an infrastructure failure and the facility did not submit an infrastructure failure event to the Department and the Patient Safety Authority within 24 hours of occurrence.

General Surgery Clinic located at Valley Medical Building:

1. Review on September 2, 2021, of the facility provided humidity logs revealed days procedure room A's max A.M. humidity readings were greater than 60 percent on July 3, 4, 5, 17, 18, 23, 24, 25 and 29, 2021 and August 1, 3, 4, 5, 7, 14, 15, 21, 22, 28 and 29, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room A's max A.M. humidity readings were greater than 70 percent on June 22, 26 and 27, 2021; July 1 and 2, 2021; July 6 through 16, 2021; July 19, 20, 21, 22, 26, 27, 28, and 30, 2021; and August 2 and 6,2021; August 8 through 13, 2021; August 17 through 20, 2021, August 23 through 27, 2021, and August 30 and 31, 2021.

Interview with EMP1, EMP3 and EMP4 September 2, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room A for June 1 through August 31, 2021. EMP1, EMP3 and EMP4 confirmed the procedure room A's humidity readings were considered out of range.

2. Review on September 2, 2021, of the facility provided humidity logs revealed days procedure room B's max A.M. humidity readings were greater than 60 percent on June 21, 22, 26 and 27, 2021; July 1 through 18, 2021; July 20 through 27, 2021; July 29 and 30, 2021 and August 1 and 2, 2021; August 4 through 25, 2021; and August 27 through 31, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room B's max A.M. humidity readings were greater than 70 percent on June 28, 29 and 30, 2021; July 19 and 28, 2021 and August 26, 2021.

Interview with EMP1, EMP3 and EMP4 September 2, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room B for June 1 through August 31, 2021. EMP1, EMP3 and EMP4 confirmed the procedure room B's humidity readings were considered out of range.

3. Review on September 2, 2021, of the facility provided humidity logs revealed days procedure room C's max A.M. humidity readings were greater than 60 percent on June 22, 26 and 27, 2021; July 1 through 5, 2021; July 8 through 15, 2021; July 17 and 18, 2021 and July 20 through 30, 2021; August 1 and 2, 2021; August 4 through 9, 2021; August 14 through 17, 2021; August 20, 21, 22, 27, 28, 29 and 31, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room C's max A.M. humidity readings were greater than 70 percent on June 21, 28, 29 and 30, 2021; July 16 and 19, 2021; July 6 and 7, 2021 and August 10 through 13, 2021; August 18, 19, 23, 24, 25, 26 and 30, 2021.

Interview with EMP1, EMP3 and EMP4 September 2, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room C for June 1 through August 31, 2021. EMP1, EMP3 and EMP4 confirmed the procedure room C's humidity's were considered out of range.

Interview with EMP1, EMP3 and EMP4 on September 2, 2021, at the time of review, confirmed these out-of-range humidity levels met the criteria of an infrastructure failure and the facility did not submit an infrastructure failure event to the Department and the Patient Safety Authority within 24 hours of occurrence.
___

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the operating practitioner failed to document awareness of elevated humidity readings and to determine proceeding with or canceling the surgical procedure for 24 of 24 applicable medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20, MR21, MR22, MR23 and MR24).

Findings include:

A request was made of EMP1, EMP2, EMP3 and EMP4 on August 27, 2021, for the facility's policy, procedure, protocol, or guideline facility practitioners follow regarding documenting in the patient's medical record a determination to proceed with a procedure or canceling a procedure when the humidity is greater than 60 percent in the procedure room. None was provided.

Interview with EMP1, EMP3 and EMP4 on August 27, 2021, at approximately 2:15 p.m. revealed the facility does not have a policy, procedure, protocol, or guideline a facility practitioner would follow regarding documenting in the patient's medical record a determination to proceed with a procedure or canceling a procedure when the humidity is greater than 60 percent in the procedure room.

Review of MR1 on August 30, 2021, revealed this patient had a surgical procedure on August 3, 2021. The humidity in the procedure room was greater than 60 percent. There was no documentation in MR1 of the practitioner's determination to proceed with the procedure or to cancel the procedure with the humidity greater than 60 percent.

Review of MR2 on August 30, 2021, revealed this patient had a surgical procedure on August 9, 2021. The humidity in the procedure room was greater than 60 percent. There was no documentation in MR2 of the practitioner's determination to proceed with the procedure or to cancel the procedure with the humidity greater than 60 percent.

Review of MR3, MR13 and MR14 on August 30, 2021, revealed these patients had a surgical procedure on August 17, 2021. The humidity in the procedure rooms was greater than 60 percent. There was no documentation in MR3, MR13 and MR14 of the practitioner's determination to proceed with the procedure or to cancel the procedure with the humidity greater than 60 percent.

Review of MR4 and MR8 on August 30, 2021, revealed these patients had a surgical procedure on August 5, 2021. The humidity in the procedure rooms was greater than 60 percent. There was no documentation in MR4 and MR8 of the practitioner's determination to proceed with the procedure or to cancel the procedure with the humidity greater than 60 percent.

Review of MR5 on August 30, 2021, revealed this patient had a surgical procedure on August 2, 2021. The humidity in the procedure rooms was greater than 60 percent. There was no documentation in MR5 of the practitioner's determination to proceed with the procedure or to cancel the procedure with the humidity greater than 60 percent.

Review of MR6 on August 30, 2021, revealed this patient had a surgical procedure on August 20, 2021. The humidity in the procedure rooms was greater than 60 percent. There was no documentation in MR6 of the practitioner's determination to proceed with the procedure or to cancel the procedure with the humidity greater than 60 percent.

Review of MR7 on August 30, 2021, revealed this patient had a surgical procedure on August 25, 2021. The humidity in the procedure rooms was greater than 60 percent. There was no documentation in MR7 of the practitioner's determination to proceed with the procedure or to cancel the procedure with the humidity greater than 60 percent.

Review of MR9 on August 30, 2021, revealed this patient had a surgical procedure on July 12, 2021. The humidity in the procedure rooms was greater than 60 percent. There was no documentation in MR9 of the practitioner's determination to proceed with the procedure or to cancel the procedure with the humidity greater than 60 percent.

Review of MR10 on August 30, 2021, revealed this patient had a surgical procedure on August 19, 2021. The humidity in the procedure rooms was greater than 60 percent. There was no documentation in MR10 of the practitioner's determination to proceed with the procedure or to cancel the procedure with the humidity greater than 60 percent.

Review of MR15 on August 30, 2021, revealed this patient had a surgical procedure on August 18, 2021, in the dental clinic. The humidity in the procedure rooms was greater than 60 percent. There was no documentation in MR15 of the practitioner's determination to proceed with the procedure or to cancel the procedure with the humidity greater than 60 percent.

Review of MR11 on August 30, 2021, revealed this patient had a surgical procedure on August 19, 2021. There was no documentation in MR11 of the practitioner's determination to proceed with the procedure or to cancel the procedure with the humidity greater than 60 percent.

Interview with EMP2 on August 30, 2021, confirmed MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR13, MR14 and MR15 had surgical procedures performed; the humidity in the procedure rooms on these days was greater than 60 percent and there was no documentation in these patients' medical records of the practitioner's determination to proceed with these procedures or to cancel these procedures with the humidity greater than 60 percent.

Review of MR16 on September 3, 2021, revealed this patient had a surgical procedure on July 16, 2021. The humidity in the procedure room was greater than 60 percent. There was no documentation in MR16 of the practitioner's determination to proceed with the procedure or to cancel the procedure with the humidity greater than 60 percent.

Review of MR17 on September 3, 2021, revealed this patient had a surgical procedure on July 14, 2021. The humidity in the procedure room was greater than 60 percent. There was no documentation in MR17 of the practitioner's determination to proceed with the procedure or to cancel the procedure with the humidity greater than 60 percent.

Review of MR18 on September 3, 2021, revealed this patient had a surgical procedure on August 9, 2021. The humidity in the procedure room was greater than 60 percent. There was no documentation in MR18 of the practitioner's determination to proceed with the procedure or to cancel the procedure with the humidity greater than 60 percent.

Review of MR19 and MR20 on September 3, 2021, revealed these patients had surgical procedures on July 6, 2021. The humidity in the procedure room was greater than 60 percent. There was no documentation in MR19 and MR20 of the practitioner's determination to proceed with the procedure or to cancel the procedure with the humidity greater than 60 percent.

Review of MR21 on September 3, 2021, revealed this patient had a surgical procedure on August 17, 2021. The humidity in the procedure room was greater than 60 percent. There was no documentation in MR21 of the practitioner's determination to proceed with the procedure or to cancel the procedure with the humidity greater than 60 percent.

Review of MR22, MR23 and MR24 on September 3, 2021, revealed these patients had surgical procedures on August 18, 2021. The humidity in the procedure room was greater than 60 percent. There was no documentation in MR22, MR23 and MR24 of the practitioner's determination to proceed with the procedure or to cancel the procedure with the humidity greater than 60 percent.

Interview with EMP2 on September 3, 2021, confirmed MR16, MR17, MR18, MR19, MR20, MR21, MR22, MR23 and MR24 had surgical procedures performed; the humidity in the procedure rooms on these days was greater than 60 percent and there was no documentation in these patients' medical records of the practitioner's determination to proceed with these procedures or to cancel these procedures with the humidity greater than 60 percent.

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

The findings were:

482.41 Tag A-0701 and Tag A-0726

The information reviewed during the survey provided evidence the facility failed to request an occupancy survey for rooms 5 and 6 in the dental clinic from the Department of Health Division of Acute and Ambulatory Care [Department] prior to utilizing these rooms as procedure rooms for surgical dental procedures; the facility failed to ensure a clean environment in procedure rooms 1 through 4 in the dental clinic and the facility failed to maintain a humidity range of 30 - 60 percent in the dental surgery clinic and ophthalmology clinic procedure rooms located in the facility's Hospital Outpatient (HOP) clinics at 675 Baltimore Drive, Wilkes-Barre and the General Surgery clinic and Plastic surgery clinic procedure rooms located at the HOP clinics at the Valley Medical Building located at 1000 East Mountain Boulevard, Wilkes-Barre

A discussion took place with the survey team and the facility's administrative staff (EMP1, EMP2, EMP3, EMP4, EMP5 and EMP6) regarding the survey team's concerns related to Governing body on August 31, 2021 at approximately 10:00 AM.


Cross reference
482.41(a) Standard: Buildings
482.41(d)(4) Ventilation, Light, Temperature Controls

Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to request an occupancy survey for rooms 5 and 6 in the dental clinic from the Department of Health Division of Acute and Ambulatory Care [Department] prior to utilizing these rooms as procedure rooms for surgical dental procedures and the facility failed to ensure a clean environment in procedure rooms 1 through 4 in the dental clinic.

Findings include:

1. Interview with EMP1 and EMP4 on August 27, 2021, confirmed the Dental clinic located at 675 Baltimore Drive, Wilkes-Barre was under the Geisinger Wyoming Valley Medical Center License.

Review on August 27, 2021, of the facility's "Amended and Restated Bylaws of the Medical Staff of Geisinger Wyoming Valley Medical Center" last approved October 26, 2016, revealed "Article XI committees and Functions...Section 11.6 Other Standing Committees In addition to the Medical Executive Committee and the Patient Safety Committee, there shall be standing committees whose purpose, function, and composition are required to comply with the regulations of the PA Department of Health..."

Review on August 27, 2021, of the Pennsylvania Hospital regulations revealed:

§ 51.5. Building occupancy. (a) New construction, alterations or renovations that provide space for patient or resident rooms or services may not be used or occupied until authorization for the occupancy has been received from the Department. (b) A health care facility shall request a preoccupancy survey at least 30 days prior to the anticipated occupancy of the facility or an addition or remodeled part thereof. The Department will conduct an onsite survey of the new or remodeled portion of the health care facility prior to granting approval for occupancy. The Department may give the authorization to occupy the new or remodeled portion of the health care facility by an interim written authorization. If interim authorization for occupancy is given, the Department will provide the health care facility with formal authorization within 30 days.


On August 27, 2021, EMP6 provided the dental clinic floor plans for March 2012 and for April 2014.

Review on August 27, 2021, of the dental clinic floor plan dated March 2013 revealed rooms 1 through 4 were labeled as procedure rooms, room 5 was labeled a recovery room and room 6 was labeled a laboratory area.

Interview with EMP6 on August 27, 2021, at the time of the review, confirmed the dental clinic floor plan dated March 2013, rooms 1 through 4 were labeled as procedure rooms, room 5 was labeled a recovery room and room 6 was labeled a laboratory area.

Review on August 27, 2021, of the dental clinic floor plan dated April 2015, revealed rooms 5 and 6 were labeled procedure rooms and the square footage of room 6 was increased.

Interview with EMP6 on August 27, 2021, at the time of review, confirmed rooms 5 and 6 were labeled procedure rooms and the square footage of room 6 was increased. EMP6 revealed the facility did not request an occupancy survey for rooms 5 and 6 prior to utilizing these rooms as procedure rooms for dental surgical procedures.

Review on August 27, 2021, of the facility's occupancy reports from March 2009 through August 2021, revealed no documentation the facility requested an occupancy survey from the Department for rooms 5 and 6 in the dental clinic located at 675 Baltimore Drive, Wilkes-Barre.

Interview with EMP1, EMP2, EMP3, EMP4, EMP5 and EMP6 on August 27, 2021, at the time of review, confirmed the facility did not request occupancy survey from the Department for rooms 5 and 6 in the dental clinic located at 675 Baltimore Drive, Wilkes-Barre. EMP1, EMP2, EMP3, EMP4, EMP5 and EMP6 confirmed these rooms 5 and 6 were used to perform surgical dental procedures on patients from April 2012 until August 27, 2021.

2. Review on August 31, 2021, of the facility's "Ambulatory Care Policy," last reviewed May 19, 2019, revealed "Purpose: To provide a safe environment the prevents the transmission of infectious diseases in the ambulatory care setting ...Procedure... 5. Cleaning of rooms or items in clinic rooms a. Cleaning of rooms horizontal surfaces and equipment must be done with EPA-registered hospital approved disinfectant. b. Each clinic area should establish routine cleaning and disinfection of environmental surfaces after each patient encounter..."

Observation on September 2, 2021, revealed an accumulation of dirt, dust, and debris on all vertical and horizontal surfaces of the instrument trays and on all surfaces of the dental technician carts in procedure rooms 1, 2, 3 and 4 in the dental clinic. There was an accumulation of white debris in the drawers of the dental technician carts in all the procedure rooms. There was also an accumulation of dust measuring the size of approximately a dime on the horizontal surfaces of the radiology equipment extending from the ceiling.

Interview with EMP1, EMP2 and EMP4 on September 2, 2021, at the time of the observations, confirmed the accumulation of dirt, dust, and debris on all vertical and horizontal surfaces of the instrument trays and on all surfaces of the dental technician carts in procedure rooms 1, 2, 3 and 4 in the dental clinic; the accumulation of white debris in the drawers of the dental technician carts in all the procedure rooms and the accumulation of dust measuring the size of approximately a dime on the horizontal surfaces of the radiology equipment extending from the ceiling.

Cross reference:
482.41(d)(4) Ventilation, Light and Temperature Controls
482.51(b) Standard: Delivery of Service (Surgical Services)
482.52(b) Standard: Delivery of Services (Anesthesia)

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to maintain a humidity range of 30 - 60 percent in the dental surgery clinic and ophthalmology clinic procedure rooms located in the facility's Hospital Outpatient (HOP) clinics at 675 Baltimore Drive, Wilkes-Barre and the General Surgery clinic and Plastic surgery clinic procedure rooms located at the HOP clinics at the Valley Medical Building located at 1000 East Mountain Boulevard, Wilkes-Barre.

Findings include:

Review on August 27, 2021, of the facility's "Temperature and Humidity Control" policy, last approved May 5, 2021, revealed "Purpose To maintain the temperature and humidity in the ...Procedure rooms for the benefit of the patient and to maintain sterility of supplies ...Policy 1. The following area will maintain the temperature and humidity within the acceptable ranges. Procedure rooms ...Humidity range 30 - 60 [percent]..."

Dental Surgery Clinic located at 675 Baltimore Drive:

A request was made of EMP1, EMP2 and EMP6 for the temperature and humidity logs for procedure rooms 5 and 6 from June 2021 through August 27, 2021. None were provided.

Interview with EMP6 on August 27, 2021, at approximately 11:00 a.m. revealed this employee was not able to provide a temperature and humidity monitoring report for room 5. EMP6 revealed there is no temperature and humidity monitoring device in procedure room 5. EMP6 also revealed there is no humidity monitoring report for room 6.

1. Review on August 27, 2021, of the facility provided humidity logs revealed days procedure room 1's max A.M. humidity readings were greater than 60 percent on June 3, 5, 12 and 19, 2021; July 5, 6, 22, 23 and 24, 2021 and August 1, 2, 4, 5, 6, 12 and 15, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 1's max A.M. humidity readings were greater than 70 percent on June 4, 6, 7, 8, 10, 13, 14, 15, 21, 22, 26, 27, 28 and 29, 2021; July 3, 6, 8, 10, 11, 13, 15, 16, 19, 20, 21, 25, 26, 27, 28, 29 and 30, 2021 and August 7, 8, 9, 10, 13, 16, 17 and 19, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 1's max A.M. humidity readings were greater than 80 percent on June 9, 20 and 30, 2021; July 1, 2, 7, 9, 12, 14, 17 and 18, 2021 and August 11, 14, 18, 20, 21, 22, 23, 24, 25 and 26, 2021.

Interview with EMP1, EMP2, EMP3, EMP4 and EMP6 on August 27, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room 1 for June 1 through August 31, 2021. EMP1, EMP2, EMP3, EMP4 and EMP6 confirmed the procedure room 1's humidity readings were considered out of range.

2. Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 2's max A.M. humidity readings were greater than 60 percent on June 12 and 24, 2021; July 22, 23 and 24, 2021 and August 1, 2, 3 and 5, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 2's max A.M. humidity readings were greater than 70 percent June 3, 4, 5, 6, 7, 13, 15, 19, 20, 22 and 26, 2021; July 3, 4, 5, 6, 8, 11, 15, 21, 27, 28 and 29, 2021 and August 4, 6, 9 and 15, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 2's max A.M. humidity readings were greater than 80 percent on June 8, 9, 10, 14, 21, 27, 28, 29, 30 and 31, 2021; July 1, 2, 7, 9, 10, 12, 13, 14, 16, 17, 18, 19, 20, 25, 26 and 30, 2021 and August 7, 8, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 and 26, 2021.

Interview with EMP1, EMP2, EMP3, EMP4 and EMP6 on August 27, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room 2 for June 1 through August 31, 2021. EMP1, EMP2, EMP3, EMP4 and EMP6 confirmed the procedure room 2's humidity readings were considered out of range.

3. Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 3's max A.M. humidity readings were greater than 60 percent on June 11, 12, 16 and 24, 2021; July 23 and 24, 2021 and August 1, 2, 3, 4 and 5, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 3's max A.M. humidity readings were greater than 70 percent on June 3, 4, 5, 6, 7, 13, 15, 19, 20, 22, 26, 28 and 29, 2021; July 3, 4, 5, 6, 8, 11, 15, 21, 22, 26, 27, 28, 29 and 30, 2021 and August 6, 7, 8, 9, 13 and 15, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 3's max A.M. humidity readings were greater than 80 percent on June 8, 9, 10, 14, 21, 27 and 30, 2021; July 1, 2, 7, 9, 10, 12, 13, 14, 16, 17, 18, 19, 21 and 25, 2021 and August 10, 11, 12, 14, 16, 17,18, 19, 20, 21, 22, 23, 24, 25 and 26, 2021.

Interview with EMP1, EMP2, EMP3, EMP4 and EMP6 on August 27, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room 3 for June 1 through August 31, 2021. EMP1, EMP2, EMP3, EMP4 and EMP6 confirmed the procedure room 3's humidity readings were considered out of range.

4. Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 4's max A.M. humidity readings were greater than 60 percent on June 11, 12, 16 and 23, 2021; July 23, 2021 and August 1, 3 and 5, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 4's max A.M. humidity readings were greater than 70 percent on June 3, 4, 5, 6, 13, 15, 19, 20 and 22, 2021; July 3, 4, 5, 6, 21, 22, 24 and 27, 2021 and August 2, 4, 6, 9 and 15, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 4's max A.M. humidity readings were greater than 80 percent on June 7, 8, 9, 10, 14, 21, 26, 27, 28, 29 and 30, 2021 ; July 1, 2, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 25, 26, 28, 29 and 30, 2021 and August 7, 8, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 25 and 26, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 4's max A.M. humidity readings were greater than 90 percent on August 24, 2021.

Interview with EMP1, EMP2, EMP3, EMP4 and EMP6 on August 27, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room 4 for June 1 through August 31, 2021. EMP1, EMP2, EMP3, EMP4 and EMP6 confirmed the procedure room 4's humidity level s were considered out of range.

Ophthalmology Clinic located at 675 Baltimore Drive:

1. Review on September 2, 2021, of the facility provided humidity logs revealed days procedure room 1's max A.M. humidity readings were greater than 60 percent on June 1, 3, 7, 8, 9, 10, 14, 15, 17, 18, 19, 21, 22, 23, 24, 26, 27, 28, 29 and 30, 2021; July 1, 4 through 10, 2021; July 5 through 10, 2021; July 12 through 31, 2021 and August 2 through 5, 2021; August 7 through 27, 2021 and August 29 and 30, 2021.

Interview with EMP1, EMP3, EMP4 and EMP14 on September 2, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room 1 for June 1 through August 31, 2021. EMP1, EMP3, EMP4 and EMP14 confirmed the procedure room 1's humidity readings were considered out of range.

2. Review on September 2, 2021, of the facility provided humidity logs revealed procedure room 1's max A.M. humidity readings were greater than 70 percent on June 2, 4, 5, 6, 11, 12, 13, 16, 20, and 25, 2021; July 2, 3 and 11, 2021 and August 1, 6, 28 and 31, 2021.

Interview with EMP1, EMP3, EMP4 and EMP14 on September 2, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room 2 for June 1 through August 31, 2021. EMP1, EMP3, EMP4 and EMP14 confirmed the procedure room 1's humidity readings were considered out of range.

Plastic Surgery located at Valley Medical Building:

1. Review on September 2, 2021, of the facility provided humidity logs revealed days procedure room A's max A.M. humidity readings were greater than 60 percent on June 2, 3,12 and 16, 2021; July 3, 4, 5 and 23, 2021 and August 3 and 5, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room A's max A.M. humidity readings were greater than 70 percent on June 4, 5, 6, 7, 13, 14, 15, 19, 20, 22, 26 and 27, 2021; July 22, 24, 25, 27 and 29, 2021 and August 1, 2, 4, 6, 7, 8, 9, 16, 17, 28, 29, 30 and 31, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room A's max A.M. humidity readings were greater than 80 percent on June 8, 9, 10, 21, 28, 29 and 30, 2021; July 1 and 2, 2021; July 6 through 21, 2021; July 26 and 30, 2021 and August 10 through 14, 2021; August 18 through 27, 2021.

Interview with EMP1, EMP3, EMP4 and EMP15 on September 2, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room A for June 1 through August 31, 2021. EMP1, EMP3, EMP4 and EMP15 confirmed the procedure room A's humidity readings were considered out of range.

2. Review on September 2, 2021, of the facility provided humidity logs revealed days procedure room B's max A.M. humidity readings were greater than 60 percent on June 23, 24 and 31 2021; and August 3, 4 and 31, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room B's max A.M. humidity readings were greater than 70 percent on June 19 and 22, 2021; July 3, 4, 5, 22, 23 and 24, 2021 and August 1, 2, 5, 6, 15, 16, 28, 29 and 30, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room B's max A.M. humidity readings were greater than 80 percent on June 20, 21, 26, 27, 28, 29, 30, 2021; July 1 and 2, 2021; July 6 through 21, 2021; and July 25 through 30, 2021 and August 7 through 14, 2021; August 17 through 27, 2021.

Interview with EMP1, EMP3, EMP4 and EMP15 on September 2, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room B for June 1 through August 31, 2021. EMP1, EMP3, EMP4 and EMP15 confirmed the procedure room B's humidity readings were considered out of range.

3. Review on September 2, 2021, of the facility provided humidity logs revealed days procedure room C's max A.M. humidity readings were greater than 60 percent on June 2 and 16, 2021 and August 3, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room C's max A.M. humidity readings were greater than 70 percent on June 3, 5, 12, 15 and 22, 2021; July 4, 5, 22, 23 and 24, 2021 and August 1, 2, 4, 5, 6, 15, 16, 29, 30 and 31, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room C's max A.M. humidity readings were greater than 80 percent on June 4, 6, 7, 8, 10, 13, 14, 19, 20, 21, 26, 27, 28 and 30, 2021; July 1, 2 and 3, 2021, July 6 through 11, 2021, July 15 through 21, 2021 and July 25 through 30, 2021 and August 7, 8, 9, 14, 17, 20, 21, 22, 25, 26, 27 and 28, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room C's max A.M. humidity readings were greater than 90 percent on June 9 and 29, 2021; July 12, 13 and 14, 2021 and August 10, 11, 12, 13, 18, 19, 23 and 24, 2021.

Interview with EMP1, EMP3, EMP4 and EMP15 on September 2, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room C for June 1 through August 31, 2021. EMP1, EMP3, EMP4 and EMP15 confirmed the procedure room C's humidity readings were considered out of range.

General Surgery Clinic located at Valley Medical Building:

1. Review on September 2, 2021, of the facility provided humidity logs revealed days procedure room A's max A.M. humidity readings were greater than 60 percent on July 3, 4, 5, 17, 18, 23, 24, 25 and 29, 2021 and August 1, 3, 4, 5, 7, 14, 15, 21, 22, 28 and 29, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room A's max A.M. humidity readings were greater than 70 percent on June 22, 26 and 27, 2021; July 1 and 2, 2021; July 6 through 16, 2021; July 19, 20, 21, 22, 26, 27, 28, and 30, 2021; and August 2 and 6,2021; August 8 through 13, 2021; August 17 through 20, 2021, August 23 through 27, 2021, and August 30 and 31, 2021.

Interview with EMP1, EMP3 and EMP4 September 2, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room A for June 1 through August 31, 2021. EMP1, EMP3 and EMP4 confirmed the procedure room A's humidity readings were considered out of range.

2. Review on September 2, 2021, of the facility provided humidity logs revealed days procedure room B's max A.M. humidity readings were greater than 60 percent on June 21, 22, 26 and 27, 2021; July 1 through 18, 2021; July 20 through 27, 2021; July 29 and 30, 2021 and August 1 and 2, 2021; August 4 through 25, 2021; and August 27 through 31, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room B's max A.M. humidity readings were greater than 70 percent on June 28, 29 and 30, 2021; July 19 and 28, 2021 and August 26, 2021.

Interview with EMP1, EMP3 and EMP4 September 2, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room B for June 1 through August 31, 2021. EMP1, EMP3 and EMP4 confirmed the procedure room B's humidity readings were considered out of range.

3. Review on September 2, 2021, of the facility provided humidity logs revealed days procedure room C's max A.M. humidity readings were greater than 60 percent on June 22, 26 and 27, 2021; July 1 through 5, 2021; July 8 through 15, 2021; July 17 and 18, 2021 and July 20 through 30, 2021; August 1 and 2, 2021; August 4 through 9, 2021; August 14 through 17, 2021; August 20, 21, 22, 27, 28, 29 and 31, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room C's max A.M. humidity readings were greater than 70 percent on June 21, 28, 29 and 30, 2021; July 16 and 19, 2021; July 6 and 7, 2021 and August 10 through 13, 2021; August 18, 19, 23, 24, 25, 26 and 30, 2021.

Interview with EMP1, EMP3 and EMP4 September 2, 2021, at the time of review, confirmed the above A.M. humidity readings in procedure room C for June 1 through August 31, 2021. EMP1, EMP3 and EMP4 confirmed the procedure room C's humidity's were considered out of range.

Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to monitor or remove sterile surgical products from procedure rooms 1 through 4 when humidity levels exceeded 60 percent and staff failed to document notification to the operating practitioner of elevated humidity readings in the dental, ophthalmology, general surgery, and plastic surgery procedure rooms.

Findings include:

1. Review on August 27, 2021, of the facility's "Temperature and Humidity Control" policy, last approved May 5, 2021, revealed "Purpose To maintain the temperature and humidity in the ...Procedure rooms for the benefit of the patient and to maintain sterility of supplies ...Policy 1. The following area will maintain the temperature and humidity within the acceptable ranges. Procedure rooms ...Humidity range 30 - 60 [percent] ...If humidity exceeds 60%, the Procedure Room responsible staff or his/her designee will monitor sterile packs in designated areas. When humidity levels exceed 70%, sterile supplies will be removed from the room. All items that are not linen will be examined for evidence of moisture contamination. If moisture contamination is present, items will be isolated to determine if they need to be removed from inventory. All linen will be reprocessed..."

Oral Surgery Clinic located at 675 Baltimore Drive:

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 1's max A.M. humidity readings were greater than 60 percent four days in June and July 2021 and seven days in August 2021; greater than 70 percent 14 days in June 2021, 17 days in July 2021 and 8 days in August 2021 and greater than 80 percent three days in June 2021, eight days in July 2021 and 10 days in August 2021.

Interview with EMP2 on August 27, 2021, at the time of review, confirmed procedure room 1's max A.M. humidity readings were greater than 60 percent four days in June and July 2021 and seven days in August 2021; greater than 70 percent 14 days in June 2021, 17 days in July 2021 and 8 days in August 2021 and greater than 80 percent three days in June 2021, eight days in July 2021 and 10 days in August 2021. EMP2 confirmed facility staff did not monitor or remove sterile surgical products from procedure room 1 when humidity levels exceeded 60 percent.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 2's max A.M. humidity readings were greater than 60 percent two days in June 2021, three days in July 2021 and four days in August 2021; greater than 70 percent 11 days in June and July 2021, and four days in August 2021 and greater than 80 percent 10 days in June 2021, 16 days in July 2021 and 18 days in August 2021.

Interview with EMP2 on August 27, 2021, at the time of review, confirmed procedure room 2's max A.M. humidity readings were greater than 60 percent two days in June 2021, three days in July 2021 and four days in August 2021; greater than 70 percent 11 days in June and July 2021, and four days in August 2021 and greater than 80 percent 10 days in June 2021, 16 days in July 2021 and 18 days in August 2021. EMP2 confirmed facility staff did not monitor or remove sterile surgical products from procedure room 1 when humidity levels exceeded 60 percent.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 3's max A.M. humidity readings were greater than 60 percent four days in June 2021, two days in July 2021 and five days in August 2021; greater than 80 percent seven days in June 2021, 14 days in July 2021 and 15 days in August 2021.

Interview with EMP2 on August 27, 2021, at the time of review, confirmed procedure room 3's max A.M. humidity readings were greater than 60 percent four days in June 2021, two days in July 2021 and five days in August 2021; greater than 80 percent seven days in June 2021, 14 days in July 2021 and 15 days in August 2021. EMP2 confirmed facility staff did not monitor or remove sterile surgical products from procedure room 1 when humidity levels exceeded 60 percent.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 4's max A.M. humidity readings were greater than 60 percent four days in June 2021, one day in July 2021 and three days in August 2021; greater than 70 percent nine days in June 2021, eight days in July 2021 and four days in August 2021; greater than 80 percent 11 days in June 2021, 21 days in July 2021 and 17 days in August 2021 and greater than 90 percent on August 24, 2021.

Interview with EMP2 on August 27, 2021, at the time of review, confirmed procedure room 4's max A.M. humidity readings were greater than 60 percent four days in June 2021, one day in July 2021 and three days in August 2021; greater than 70 percent nine days in June 2021, eight days in July 2021 and four days in August 2021; greater than 80 percent 11 days in June 2021, 21 days in July 2021 and 17 days in August 2021 and greater than 90 percent on August 24, 2021. EMP2 confirmed facility staff did not monitor or remove sterile surgical products from procedure room 1 when humidity levels exceeded 60 percent.

Interview with EMP2 on August 27, 2021, at approximately 2:00 p.m. revealed facility staff did not begin monitoring the sterile surgical supply packages and equipment in procedure rooms 1 through 4 for condensation until August 20, 2021 and the facility did not remove any sterile surgical packages or equipment from procedure rooms 1 through 4 until August 27, 2021.

Ophthalmology Clinic located at 675 Baltimore Drive:

Review on September 2, 2012, of the facility provided humidity logs revealed procedure room 1's max A.M. humidity readings were greater than 60 percent 20 days in June 2021, 29 days in July 2021 and 27 days in August 2021 and greater than 70 percent 10 days in June 2021, three days in July 2021 and four days in August 2021.

Interview with EMP1 on September 2, 2012, at approximately 11:00 a.m. revealed facility staff did not begin monitoring the sterile surgical supply packages and equipment in the ophthalmology clinic procedure rooms for condensation and the facility did not remove any sterile surgical packages or equipment from procedure rooms until August 27, 2021.

Plastic Surgery clinic located at the Valley Medical Building:

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room A's max A.M. humidity readings were greater than 60 percent four days in June 2021, four days in July 2021 and three days in August 2021; greater than 70 percent 2 days in June and six days in July 2021, and nine days in August 2021 and greater than 80 percent 7 days in June 2021, 22 days in July 2021 and 15 days in August 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room B's max A.M. humidity readings were greater than 60 percent three days in June 2021 and two days in August 2021; greater than 70 percent 12 days in June and six days in July 2021, and 13 days in August 2021 and greater than 80 percent 7 days in June 2021, 22 days in July 2021 and 22 days in August 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room C's max A.M. humidity readings were greater than 60 percent two days in June 2021 and one day in August 2021; greater than 70 percent 5 days in June and July 2021, and 10 days in August 2021 and greater than 80 percent 14 days in June 2021, 19 days in July 2021 and 12 days in August 2021.

Interview with EMP1 on September 2, 2012, at approximately 11:15 a.m. revealed facility staff did not begin monitoring the sterile surgical supply packages and equipment in the plastic surgery clinic procedure rooms for condensation and the facility did not remove any sterile surgical packages or equipment from procedure rooms until August 27, 2021.

General Surgery Clinic located at the Valley Medical Building:

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room A's max A.M. humidity readings were greater than 60 percent nine days in July 2021 and 11 days in August 2021; greater than 70 percent three days in June, 21 days in July 2021, and 19 days in August 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room B's max A.M. humidity readings were greater than 60 percent four days in June 2021; 28 days in July 2021 and 26 days in August 2021; greater than 70 percent three days in June, two days in July 2021, and one day in August 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room C's max A.M. humidity readings were greater than 60 percent three days in June 2021; 26 days in July 2021 and 19 days in August 2021; greater than 70 percent four days in June, 2 days in July 2021, and 13 days in August 2021.

Interview with EMP1 on September 2, 2012, at approximately 11:30 a.m. revealed facility staff did not begin monitoring the sterile surgical supply packages and equipment in the general surgery clinic procedure rooms for condensation and the facility did not remove any sterile surgical packages or equipment from procedure rooms until August 27, 2021.

2. A request was made of EMP1, EMP2, EMP3 and EMP4 on August 27, 2021, for the facility's policy, procedure, protocol, or guideline facility staff follow regarding notifying the operating dentist of elevated humidity readings in the procedure rooms. None was provided.

Interview with EMP1, EMP3 and EMP4 on August 27, 2021, at approximately 2:15 p.m. revealed the facility does not have a policy, procedure, protocol, or guideline facility staff follow regarding notifying the operating practitioner of elevated humidity readings in the procedure rooms.

Review on August 27, 2021, of the facility's "Temperature and Humidity Control" policy, last approved May 5, 2021, revealed "Purpose To maintain the temperature and humidity in the ...Procedure rooms Policy 1. The following area will maintain the temperature and humidity within the acceptable ranges. Procedure rooms ...Humidity range 30 - 60 [percent] ..."

Review on August 27, 2021, of the facility provided humidity logs revealed days procedure room 1's max A.M. humidity readings were greater than 60 percent on June 3, 5, 12 and 19, 2021; July 5, 6, 22, 23 and 24, 2021 and August 1, 2, 4, 5, 6, 12 and 15, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 1's max A.M. humidity readings were greater than 70 percent on June 4, 6, 7, 8, 10, 13, 14, 15, 21, 22, 26, 27, 28 and 29, 2021; July 3, 6, 8, 10, 11, 13, 15, 16, 19, 20, 21, 25, 26, 27, 28, 29 and 30, 2021 and August 7, 8, 9, 10, 13, 16, 17 and 19, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 1's max A.M. humidity readings were greater than 80 percent on June 9, 20 and 30, 2021; July 1, 2, 7, 9, 12, 14, 17 and 18, 2021 and August 11, 14, 18, 20, 21, 22, 23, 24, 25 and 26, 2021.

Interview with EMP1 and EMP2 on August 27, 2021, revealed the dentist performed surgical procedures in these rooms on the above dates. EMP1 revealed procedures were not performed on the weekends.

There was no documentation indicating facility staff notified the operating dentist of the elevated humidity readings.

Interview with EMP1 on August 27, 2021, at the time of the review, confirmed there was no documentation indicating facility staff notified the operating dentist of the elevated humidity readings.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 2's max A.M. humidity readings were greater than 60 percent on June 12 and 24, 2021; July 22, 23 and 24, 2021 and August 1, 2, 3 and 5, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 2's max A.M. humidity readings were greater than 70 percent on June 3, 4, 5, 6, 7, 13, 15, 19, 20, 22 and 26, 2021; July 3, 4, 5, 6, 8, 11, 15, 21, 27, 28 and 29, 2021 and August 4, 6, 9 and 15, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 2's max A.M. humidity readings were greater than 80 percent on June 8, 9, 10, 14, 21, 27, 28, 29, 30 and 31, 2021; July 1, 2, 7, 9, 10, 12, 13, 14, 16, 17, 18, 19, 20, 25, 26 and 30, 2021 and August 7, 8, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 and 26, 2021.

Interview with EMP1 and EMP2 on August 27, 2021, revealed the dentist performed surgical procedures in these rooms on the above dates. EMP1 revealed procedures were not performed on the weekends.

There was no documentation indicating facility staff notified the operating dentist of the elevated humidity readings.

Interview with EMP1 on August 27, 2021, at the time of the review, confirmed there was no documentation indicating facility staff notified the operating dentist of the elevated humidity readings.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 3's max A.M. humidity readings were greater than 60 percent on June 11, 12, 16 and 24, 2021; July 23 and 24, 2021 and August 1, 2, 3, 4 and 5, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 3's max A.M. humidity readings were greater than 70 percent on June 3, 4, 5, 6, 7, 13, 15, 19, 20, 22, 26, 28 and 29, 2021; July 3, 4, 5, 6, 8, 11, 15, 21, 22, 26, 27, 28, 29 and 30, 2021 and August 6, 7, 8, 9, 13 and 15, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 3's max A.M. humidity readings were greater than 80 percent on June 8, 9, 10, 14, 21, 27 and 30, 2021; July 1, 2, 7, 9, 10, 12, 13, 14, 16, 17, 18, 19, 21 and 25, 2021 and August 10, 11, 12, 14, 16, 17,18, 19, 20, 21, 22, 23, 24, 25 and 26, 2021.

Interview with EMP1 and EMP2 on August 27, 2021, revealed the dentist performed surgical procedures in these rooms on the above dates. EMP1 revealed procedures were not performed on the weekends.

There was no documentation indicating facility staff notified the operating dentist of the elevated humidity readings.

Interview with EMP1 on August 27, 2021, at the time of the review, confirmed there was no documentation indicating facility staff notified the operating dentist of the elevated humidity readings.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 4's max A.M. humidity readings were greater than 60 percent on June 11, 12, 16 and 23, 2021; July 23, 2021 and August 1, 3 and 5, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 4's max A.M. humidity readings were greater than 70 percent on June 3, 4, 5, 6, 13, 15, 19, 20 and 22, 2021; July 3, 4, 5, 6, 21, 22, 24 and 27, 2021 and August 2, 4, 6, 9 and 15, 2021.

Review on August 27, 2021, of the facility provided humidity logs revealed procedure room 3's max A.M. humidity readings were greater than 80 percent on June 7, 8, 9, 10, 14, 21, 26, 27, 28, 29 and 30, 2021; July 1, 2, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 25, 26, 28, 29 and 30, 2021 and August 7, 8, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 25 and 26, 2021.

Interview with EMP1 and EMP2 on August 27, 2021, revealed the dentist performed surgical procedures in these rooms on the above dates. EMP1 revealed procedures were not performed on the weekends.

There was no documentation indicating facility staff notified the operating dentist of the elevated humidity readings.

Interview with EMP1 on August 27, 2021, at the time of the review, confirmed there was no documentation indicating facility staff notified the operating dentist of the elevated humidity readings.

Interview with EMP1 on August 27, 2021, at approximately 11:30 a.m. revealed nursing staff always notify the operating dentist regarding an elevation in humidity in the procedure rooms.

Interview with EMP1 on August 27, 2021, at the time of the review, confirmed there was no documentation indicating facility staff notified the operating dentist of elevated humidity readings in procedure rooms 1 through 6 in order that the operating dentist could determine whether to proceed with performing the operative procedure or to cancel the operative procedure.

Interview with EMP2 on August 27, 2021, at approximately 11:00 a.m. revealed the facility was not monitoring the humidity readings in procedure rooms 5 and 6 because there are no humidity monitoring devices in these procedure rooms.

Interview with EMP1 on August 27, 2021, at approximately 9:45 a.m. revealed an increase in humidity could increase the possibility of an infection in a patient's mouth due to moisture on the surgical instruments.

Review on September 2, 2021, of the facility provided humidity logs revealed days procedure room 1's max A.M. humidity readings were greater than 60 percent on June 1, 3, 7, 8, 9, 10, 14, 15, 17, 18, 19, 21, 22, 23, 24, 26, 27, 28, 29 and 30, 2021; July 1, 4 through 10, 2021; July 5 through 10, 2021; July 12 through 31, 2021 and August 2 through 5, 2021; August 7 through 27, 2021 and August 29 and 30, 2021.

Interview with EMP1, EMP3, EMP4 and EMP14 on September 2, 2021, at the time of review, revealed the operating ophthalmologist performed surgical procedures in these rooms on the above dates. EMP1 revealed procedures were not performed on the weekends.

There was no documentation indicating facility staff notified the operating ophthalmologist of the elevated humidity readings.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room 1's max A.M. humidity readings were greater than 70 percent on June 2, 4, 5, 6, 11, 12, 13, 16, 20, and 25, 2021; July 2, 3 and 11, 2021 and August 1, 6, 28 and 31, 2021.

Interview with EMP1, EMP3, EMP4 and EMP14 on September 2, 2021, at the time of review, revealed the operating ophthalmologist performed surgical procedures in these rooms on the above dates. EMP1 revealed procedures were not performed on the weekends.

There was no documentation indicating facility staff notified the operating ophthalmologist of the elevated humidity readings greater than 70 percent in procedure room 1 in June, July, and August 2021.

Interview with EMP1 on September 2, 2021, at the time of the review, confirmed there was no documentation indicating facility staff notified the operating ophthalmologist of the elevated humidity readings.

Review on September 2, 2021, of the facility provided humidity logs revealed days procedure room A's max A.M. humidity readings were greater than 60 percent on June 2, 3,12 and 16, 2021; July 3, 4, 5 and 23, 2021 and August 3 and 5, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room A's max A.M. humidity readings were greater than 70 percent on June 4, 5, 6, 7, 13, 14, 15, 19, 20, 22, 26 and 27, 2021; July 22, 24, 25, 27 and 29, 2021 and August 1, 2, 4, 6, 7, 8, 9, 16, 17, 28, 29, 30 and 31, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room A's max A.M. humidity readings were greater than 80 percent on June 8, 9, 10, 21, 28, 29 and 30, 2021; July 1 and 2, 2021; July 6 through 21, 2021; July 26 and 30, 2021 and August 10 through 14, 2021; August 18 through 27, 2021.

Interview with EMP1, EMP3, EMP4 and EMP15 on September 2, 2021, at the time of review, revealed the operating plastic surgeon performed surgical procedures in this room on the above dates. EMP1 revealed procedures were not performed on the weekends.

There was no documentation indicating facility staff notified the operating plastic surgeon of the elevated humidity readings.

Review on September 2, 2021, of the facility provided humidity logs revealed days procedure room B's max A.M. humidity readings were greater than 60 percent on June 23, 24 and 31 2021; and August 3, 4 and 31, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room B's max A.M. humidity readings were greater than 70 percent on June 19 and 22, 2021; July 3, 4, 5, 22, 23 and 24, 2021 and August 1, 2, 5, 6, 15, 16, 28, 29 and 30, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room B's max A.M. humidity readings were greater than 80 percent on June 20, 21, 26, 27, 28, 29, 30, 2021; July 1 and 2, 2021; July 6 through 21, 2021; and July 25 through 30, 2021 and August 7 through 14, 2021; August 17 through 27, 2021.

Interview with EMP1, EMP3, EMP4 and EMP15 on September 2, 2021, at the time of review, revealed the operating plastic surgeon performed surgical procedures in this room on the above dates. EMP1 revealed procedures were not performed on the weekends.

There was no documentation indicating facility staff notified the operating plastic surgeon of the elevated humidity readings.

Review on September 2, 2021, of the facility provided humidity logs revealed days procedure room C's max A.M. humidity readings were greater than 60 percent on June 2 and 16, 2021 and August 3, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room C's max A.M. humidity readings were greater than 70 percent on June 3, 5, 12, 15 and 22, 2021; July 4, 5, 22, 23 and 24, 2021 and August 1, 2, 4, 5, 6, 15, 16, 29, 30 and 31, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room C's max A.M. humidity readings were greater than 80 percent on June 4, 6, 7, 8, 10, 13, 14, 19, 20, 21, 26, 27, 28 and 30, 2021; July 1, 2 and 3, 2021, July 6 through 11, 2021, July 15 through 21, 2021 and July 25 through 30, 2021 and August 7, 8, 9, 14, 17, 20, 21, 22, 25, 26, 27 and 28, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room C's max A.M. humidity readings were greater than 90 percent on June 9 and 29, 2021; July 12, 13 and 14, 2021 and August 10, 11, 12, 13, 18, 19, 23 and 24, 2021.

Interview with EMP1, EMP3, EMP4 and EMP15 on September 2, 2021, at the time of review, revealed the operating plastic surgeon performed surgical procedures in this room on the above dates. EMP1 revealed procedures were not performed on the weekends.

There was no documentation indicating facility staff notified the operating plastic surgeon of the elevated humidity readings.

Interview with EMP1 on September 2, 2021, at the time of the review, confirmed there was no documentation indicating facility staff notified the operating plastic surgeon of the elevated humidity readings.

Review on September 2, 2021, of the facility provided humidity logs revealed days procedure room A's max A.M. humidity readings were greater than 60 percent on July 3, 4, 5, 17, 18, 23, 24, 25 and 29, 2021 and August 1, 3, 4, 5, 7, 14, 15, 21, 22, 28 and 29, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room A's max A.M. humidity readings were greater than 70 percent on June 22, 26 and 27, 2021; July 1 and 2, 2021; July 6 through 16, 2021; July 19, 20, 21, 22, 26, 27, 28, and 30, 2021; and August 2 and 6,2021; August 8 through 13, 2021; August 17 through 20, 2021, August 23 through 27, 2021, and August 30 and 31, 2021.

Interview with EMP1, EMP3 and EMP4 on September 2, 2021, at the time of review, revealed the operating general surgeon performed surgical procedures in this room on the above dates. EMP1 revealed procedures were not performed on the weekends.

There was no documentation indicating facility staff notified the operating general surgeon of the elevated humidity readings.

Review on September 2, 2021, of the facility provided humidity logs revealed days procedure room B's max A.M. humidity readings were greater than 60 percent on June 21, 22, 26 and 27, 2021; July 1 through 18, 2021; July 20 through 27, 2021; July 29 and 30, 2021 and August 1 and 2, 2021; August 4 through 25, 2021; and August 27 through 31, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room B's max A.M. humidity readings were greater than 70 percent on June 28, 29 and 30, 2021; July 19 and 28, 2021 and August 26, 2021.

Interview with EMP1, EMP3 and EMP4 on September 2, 2021, at the time of review, revealed the operating general surgeon performed surgical procedures in this room on the above dates. EMP1 revealed procedures were not performed on the weekends.

There was no documentation indicating facility staff notified the operating general surgeon of the elevated humidity readings.

Review on September 2, 2021, of the facility provided humidity logs revealed days procedure room C's max A.M. humidity readings were greater than 60 percent on June 22, 26 and 27, 2021; July 1 through 5, 2021; July 8 through 15, 2021; July 17 and 18, 2021 and July 20 through 30, 2021; August 1 and 2, 2021; August 4 through 9, 2021; August 14 through 17, 2021; August 20, 21, 22, 27, 28, 29 and 31, 2021.

Review on September 2, 2021, of the facility provided humidity logs revealed procedure room C's max A.M. humidity readings were greater than 70 percent on June 21, 28, 29 and 30, 2021; July 16 and 19, 2021; July 6 and 7, 2021 and August 10 through 13, 2021; August 18, 19, 23, 24, 25, 26 and 30, 2021.

Interview with EMP1, EMP3 and EMP4 on September 2, 2021, at the time of review, revealed the operating general surgeon performed surgical procedures in this room on the above dates. EMP1 revealed procedures were not performed on the weekends.

There was no documentation indicating facility staff notified the operating general surgeon of the elevated humidity readings.

Interview with EMP1 on September 2, 2021, at the time of the review, confirmed there was no documentation indicating facility staff notified the operating general surgeon of the elevated humidity readings.

Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure emergency intubation boxes and manual resuscitator bags were available in each procedure room should a patient require emergency intubation while under anesthesia.

Findings include:

Review on September 8, 2021, of the facility's "Sedation - Moderate & Deep Sedation by Non-Anesthesia Providers" policy, last reviewed May 15, 2019, revealed "...Policy: It must be recognized by all providers that depth of sedation is a continuum with no boundaries and that any level of sedation can be attained buy use of any sedative drug, by any route of administration ...The continuum of sedation: ...Deep Sedation/Analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate ...Because sedation in a continuum, it is not always possible to predict how an individual patient will respond to a dose of a sedative medication. Practitioners intending to produce a given level of sedation must be able to rescue patients whose level of sedation becomes deeper than initially intended, providing respiratory or hemodynamic support, while returning them to the intended level of sedation ...Facility Requirements: in locations where sedation is being performed, age-appropriate emergency equipment must be immediately available ... "

Interview with EMP2 on August 31, 2021, at approximately 2:15 p.m. revealed the dental clinic currently has two dentists who have been credentialed to administer anesthesia during dental procedures and there are six procedure rooms. EMP2 revealed the dentists administer Ketamine (an intravenous general anesthetic indicated as the sole anesthetic agent for diagnostic and surgical procedures), Propofol (an intravenous hypnotic agent used for initiation and maintenance of Monitored Anesthesia Care (MAC) sedation, combined sedation and regional anesthesia, induction of general anesthesia, and maintenance of general anesthesia), Fentanyl (an intravenous sedative given as part of a balance technique for sedation or general anesthesia) and Versed (an intravenous narcotic analgesic indicated for general anesthesia).

Observation on August 31, 2021, of procedure room 4 revealed a black box labeled "Intubation Box". This box contained various sizes of endotracheal tubes (a tube that is placed in the windpipe through the mouth or nose to maintain an unobstructed passageway to deliver oxygen to the lungs when under anesthesia); two laryngoscopes (a lighted instrument for examining or placing an endotracheal tube) and nasopharyngeal tubes (a tube that is designed to be inserted into the nasal passageway to secure an open airway). Further observation revealed no manual resuscitator (a self-refilling bag-valve-mask used to administer artificial respiration of intubated patients) bags as part of the Intubation Box.

Interview with EMP2 on August 31, 2021, 2:20 p.m. confirmed the Intubation Box in procedure room 4 and its contents. EMP2 also confirmed there was no manual resuscitator bag in the Intubation Box should a patient require emergency intubation while under anesthesia.

Interview with EMP2 on August 31, 2021, at approximately 2:25 p.m. confirmed the dental clinic does not have an intubation box and manual resuscitator bag in each procedure room should a patient require emergency intubation while under anesthesia. EMP2 revealed the clinic does have an emergency cart with available supplies and this cart is located behind closed doors in the hallway. EMP2 revealed the contents in the intubation box would be used in an emergency should the dentist need to intubate a person before the emergency cart is brought to the procedure room. EMP2 confirmed this emergency cart is not readily available.