HospitalInspections.org

Based on document review and interview, the facility failed to:
1. Utilize its Quality Assessment and Performance Improvement (QAPI) Program to ensure that action plans proposed to correct identified problems related to pressure injury prevention and management were implemented;
2. Ensure that data collected collected on Relative Humidity (RH) in operating rooms were analyzed and corrective actions implemented.

Findings include:

1. Review of the facility's QAPI data showed pressure injury rates for the four (4) quarters of 2019 were above the National Nursing Database of Nursing Quality Indicators (NDNQI) benchmark of 0.57 as follows:

January - March 2019 = 0.64
April - June 2019 = 1.7
July - September 2019 = 1.2
October - December 2019 = 0.97

Review of the quality meeting minutes for 2018 and 2019 noted discussions on the increasing rates of Hospital Acquired Pressure Ulcers (HAPU). In March 2019, a wound care education plan (Wound Care Essential) was rolled out for the medical-surgical nursing staff.

Review of attendance record for the "Wound Care Essential" inservice training revealed that only 50% of the medical- surgical nursing staff have been trained.

During an interview with the Chief Nursing Officer on 1/28/20 at 12:15 pm, she stated we have been meeting and have discussed the need for nurses to attend the mandatory wound care classes.

During an interview with the Assistance Vice President of Nursing Education on 1/28/2020 at 11:57 am, she acknowledged that the "Wound Care Essential inservice" for medical-surgical nurses have not been completed.


2. The facility's policy and procedure titled "Temperature, humidity and Ventilation in the Operating Rooms/procedure areas" last revised on 12/19 notes that the acceptable range for Relative Humidity (RH) is 30 to 60%.

Review of Operating Room log titled "OR & Procedure Rooms Daily Rounds" from 1/1/2020 to 1/24/20 revealed Relative Humidity levels were less than 20% for the past 14 days in OR #s 9, 10, 11, 12 and the two procedure rooms (GI Lab 1 and 2).
On 1/22/2020 the RH of OR#s 9 and 10 were 7%, OR#s 11 and 12 were 8%, the GI Lab I and II were 9% and 7% respectively.
On 1/23/2020, the RH levels in OR #s 9, 10, 11, 12 and the two GI Labs were 0%.

Review of Temperature and RH log for 2018 and 2019 revealed that the RH for OR #s 9, 10, 11, 12 and the two procedure rooms were continuously below acceptable range for the two years.

There was no documented evidence that action plans were implemented to correct the identified problem.

During interview on 1/22/2020 at 2:00 PM with Staff A, (Facilities Manager) and Staff B, (Supervisor, Plant Operations) they acknowledged findings and reported that corrective actions have not been implemented to fix the RH problem in the four ORs and two procedure rooms in Zone 2 - Surgical Suite.

Based on medical record review, document review and interview, in three (3) of sixteen (16) medical records reviewed, nursing staff failed to:
1. Implement the facility's policy and procedure for the prevention and management of pressure injury (Patients #s 1, 4 and 5);
2. Implement action plans proposed to correct identified problems related to pressure injury prevention and management.

These failures place patients at risk for development of pressure injuries.

Findings include:

See A 283 and A 395.

Based on medical record review, document review and interview, in three (3) of sixteen (16) medical records reviewed, it was determined the facility failed to ensure that patients identified at risk for developing pressure ulcers were assessed daily and received care in accordance with the facility's policy and procedure (Patients #1, 4 and 5).

This failure may have placed patient at risk for developing pressure injuries.

Findings include:

The facility's policy titled "Skin Care," not dated, stated: "All patients will be assessed for skin breakdown and pressure ulcer risk on admission and then daily" ... The patient's skin will be monitored for integrity and the prevention of pressure injuries areas as well as the appropriate treatment as needed ... Nurses are expected to document with respect to size and progression of ulcers. Measures to promote patients wound healing and minimize infection will be instituted."

Review of medical record for Patient #1 revealed: on 03/07/19, the patient was sent from a nursing home to the facility with complaints of altered mental status, lethargy (tiredness), tachycardia (rapid heart rate), and she was warm to touch. Documentation showed the patient had limited mobility, was incontinent of urine, and suffered from malnutrition. The nursing initial skin assessment on 3/8/19 indicated the patient had a Stage II pressure ulcer at the sacral area and was considered "at risk" for decubiti formation evidenced by a Braden risk score (tool used to predict the risk of developing pressure ulcer) of 15 (Mild Risk Score 15-18). The nursing staff documented implementation of a skin care protocol and orders for wound care upon the patient admission.

On 3/23/19, the nursing staff assessed the wound as a Stage III measuring 2 centimeter (cm) in length by 1 cm in width and they described it as "deteriorating, necrotic tissue/unable to stage, slough, surrounding erythema (redness), tender". The patient's physician was notified, and a wound care consult was ordered and obtained as per protocol.

There was no documented evidence that this patient with a stage II sacral ulcer on admission was appropriately assessed; nursing initial assessment identified the patient "at mild risk" with a Braden score of 15. In view of the patient's limited mobility, malnourishment, and urine incontinence, the patient met the criteria for being at a high risk for pressure ulcers.

From 3/16/19 to 3/22/19, there was no documented evidence that nursing staff identified the patient's deteriorating pressure ulcer until 3/23/19.

On 3/25/19, the wound clinician's note indicated sacral wound was at this point a Stage III ulcer measuring 5 cm in length by 2 cm in width with small drainage but no evidence of infection. The patient was discharged on 3/29/19 to a skilled Nursing Facility.

The next day, on 3/30/19, the patient was brought back to the facility by ambulance with an elevated temperature. The patient was readmitted with a diagnosis of sepsis and pressure ulcer Stage IV.

During an interview with Staff V, Registered Nurse on 1/27/20 at 11:15AM, she confirmed the patient was "at high risk" for pressure ulcer and that the wound dressing should have been removed and wound assessed at least daily as per the facility skin care protocol.


Review of medical record for Patient #4 revealed that this 77-year-old female was admitted to a medical-surgical unit on 10/30/19 at 11:15 PM for severe abdominal pain, low blood pressure and rapid heart rate.

The initial skin assessment of the patient on 10/30/19 at 11:15 PM, noted intact skin and a Braden Score of 17 (Mild Risk Score 15-18).

On 11/04/19, four days later, nursing staff identified a Stage III sacral ulcer.

There was no documented evidence in the medical record of a daily skin assessment from 10/30/19 until 11/4/19, therefore, early recognition and treatment of the sacral pressure ulcer was missed.


Review of medical record for Patient # 5 identified that the patient was admitted to the medical unit on 10/31/19 at 2:09 PM for difficulties with breathing and Chronic Respiratory Failure.

The nurse's initial assessment on 10/31/19 at 2:09 PM noted the patient had no pressure ulcers, was incontinent and was assigned a Braden Score of 14 (Moderate Risk Score 13-14).

On 11/4/19, three days later, nurses identified a Stage III pressure ulcer to the patient's right buttock.

There was no documented evidence of a daily skin assessment from 10/31/19 to 11/4/19. The deterioration of the patient's skin condition was not timely recognized and treated.

During an interview with Staff Q, the Vice President of Nursing Education on 1/28/20 at 12:30 PM, she acknowledged these findings.

These findings were shared with nursing leadership, and the Director of Quality on 1/28/20 at 1:30 PM.

Based on staff interview, document review and observation, the facility failed to provide a safe functional and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice, specifically, infection control guidelines.

This failure may place patients at risk for infection.

Findings include:

Review of the facility "Infection Control's Risk Assessment" report dated 7/6/2016 included a recommendation for the removal of portable coolers from Zone 2, in reference to the Association of PeriOperative Registered Nurses (AORN ) Guidelines 2016, that notes: "Free Standing devices: fans, portable HEPA (High-Efficiency Particulate Air) filter devices, humidifiers, air conditioners and dehumidifiers should not be used in restricted areas or CSP (Central Sterile Processing)".

The report concluded that they are unable to remove the portable cooling units at this time due to the building infrastructure.

During the tour of the facility's Zone 2 - Surgical Suite on 1/24/20 at 11:55 AM, portable coolers were observed in Gastrointestinal (GI) Lab #1 and Operating Room (OR) # 9.

Failure to maintain safe air handling systems in operating rooms can compromise the sterility of the operating room and sterile corridor, may facilitate entry of pathogenic organisms and other contaminants into the operating rooms and poses an infection hazard to patient undergoing surgical procedure.

During interview of Staff B (Supervisor Plant Operations) on 1/22/2020 at 2:00pm, he stated that the facility installed portable coolers in OR#s 9, 12 and the two procedure rooms (GI Lab 1 and 2) to accomplish the required OR temperature range because the Heating, Ventilation, and Air Conditioning (HVAC) system was ineffective. Staff B reported that the problem with the HVAC system has not been fixed.

Based on observation, document review and staff interview, in six (6) of six (6) Operating Rooms (OR) and procedure rooms, the facility failed to maintain an acceptable range of Relative Humidity (RH) in accordance with its policy and procedures and generally acceptable standards of practice.

This failure increases the chance of electrostatic discharge that may result in fire.

Findings include:

Review of Facility Guidelines Institute (FGI) 2010 notes that the acceptable range of Relative Humidity (RH) is between 30-60%. "Low Relative Humidity increases the chances of electrostatic discharge that could harm or interfere with electromedical equipment, and potentially spark a fire, which may cause fire in the operating rooms due to lack of proper humidity, enriched oxygen atmosphere, flammable anesthetics and presence of ignition sources; curtery or laser use."

The facility's policy and procedure titled "Temperature, humidity and Ventilation in the Operating Rooms/procedure areas" last revised on 12/19 describes the following: "If the operating rooms/procedure rooms are out of range for more than 2 hours, the procedure will be delayed until the temp/humidity/pressure are within acceptable range. If the humidity reading is from 0-30%, the room is closed until repairs are made".


During the tour of the facility's OR suite on 1/22/20 between 11:30 AM -12:30 PM, it was observed that OR#s 9, 11 and 12 were in use. OR # 10 had an RH of 14%; however, the RH for OR #s 9, 11 and 12 could not be determined as they were being used.

Review of OR log titled "OR & Procedure Rooms Daily Rounds" from 1/1/2020 to 1/24/20 revealed RH levels were less than 20% for the past 14 days in OR #s 9, 10, 11, 12 and the two procedure rooms (GI Lab 1 and 2).
On 1/22/2020 the RH of OR#s 9 and 10 were 7%, OR#s 11 and 12 were 8%, the GI Lab I and II were 9% and 7% respectively.
On 1/23/2020, the RH levels in OR #s 9, 10, 11, 12 and the two GI Labs were 0%.

Review of Temperature and RH log for 2018 and 2019 revealed that the RH for OR #s 9, 10, 11, 12 and the two procedure rooms were continuously below acceptable range for the two years.

There was no documented evidence that the facility implemented its policy and procedure to delay surgeries/procedures until the RH in the rooms are within the acceptable range.

The use of ORs with low RH was also confirmed on interview of Staff O, (Surgical Technician) on 1/28/20 at 11:15 AM and Staff X, (Manager, Surgical Services) on 1/28/20 at 12:24 PM.

During interview on 1/22/2020 at 2:00 PM with Staff A, (Facilities Manager) and Staff B, (Supervisor, Plant Operations) they acknowledge that the RH for Zone 2 - Surgical Suite that contained four ORs and two procedure rooms have been out of compliance since 2016 due to the inefficient Heating, Ventilation and Air Conditioning (HVAC) system.