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Based on review of documentation and interview, it was determined that the facility failed to keep temperature and humidity at acceptable levels in the OR and SPD rooms.

Findings were:

Review of the facility policy "Operating Rooms - Temperature, Humidity and Ventilation" dated 1/9/2019 reflected in part: " ...Humidity: The relative humidity of air supplied to all required areas requiring monitoring will be done daily prior to the start of the first case by department staff for local monitors. When possible, central adjustments will be made to maintain relative humidity within 20-60%. Should the humidity be found lower than 30%, the type of procedure needing to be done that requires the use of electrical equipment will be accessed for urgency. Manufacture recommendations for electrical equipment use in a low humidity environment will be considered. At lower than 20% no procedure will be performed until the humidity has been reestablished in range ...Temperature For Procedure areas: Temperature of the operating rooms should be monitored with optimum temp range at 68 to 75 degrees Fahrenheit. 1. Each surgical suite shall have separate temperature controls. 2. Operating temperatures shall be logged daily. If the temperature is found to be out of range in OR/procedural area, the physician should be notified to determine if the levels could negatively affect patient care. If the physician opts to proceed with the case, this will be documented on the Room Temperature and Humidity Log.

According to an article entitled "Relative Humidity Levels in the Operating Room Joint Communication to Healthcare Delivery Organizations 2015" it was stated in part: "Relative humidity may affect the operation of some electro-medical equipment used in the OR, particularly with older model electro-medical equipment. This equipment may malfunction unexpectedly. Too low humidity levels may also impact calibration. Larger electrostatic discharge (ESD) pulses may create a risk of destruction of parts, premature failure, and erratic behavior of software that is "confusion" from ESD pulses. And, in an environment where humidity is low, a person can more easily become "charged" and receive an electrostatic shock when coming in contact with medical equipment."

Review of the facility's OR (Operating Rooms) Temperature and Humidity Logs reflected the following at the top of the log: "Range for temperature should be between 68 to 72 degrees Fahrenheit. Humidity should be between 20% and 60%. Please notify maintenance if out of range for either component. Make note of action in comments section."

Review of 3 months of OR Room Temperature and Humidity Logs for OR Room 1, OR Room 2, Soft Goods, SPD (Sterile processing department) and Decon (Decontamination Room) found the following discrepancies:

In February 2022, the humidity in OR Room 1 was out of range for 9 of 20 recorded days. Temperature in OR Room 1 was out of range for 20 of 20 recorded days. Humidity and temperatures were not recorded on the weekends.
In February 2022, the humidity in OR Room 2 was out of range for 7 of 21 recorded days. T Humidity and temperatures were not recorded on the weekends. Temperature in OR Room 2 as out of range for 19 of 21 recorded days.
In February 2022, the humidity in the "soft goods" room was out of range for 19 of 19 recorded days. Temperature in the "soft goods" room was out of range for 5 of 19 recorded days. Humidity and temperatures were not recorded on the weekends.
In February 2022 the humidity in the SPD (sterile processing) was out of range for 18 of 21 recorded days. Temperature in the SPD was out of range for 11 of 21 recorded days. Humidity and temperatures were not recorded on the weekends.
In February 2022 the humidity in the decon (decontamination room) was out of range for 13 of 21 recorded days. The Temperature in the decon room was out of range for 16 of 21 recorded days. Humidity and temperatures were not recorded on the weekends.

In March 2022 the humidity in the OR Room 1 was out of range for 3 of 23 recorded days. The Temperature in the OR Room 1 was out of range for 24 of 24 recorded days. Humidity and temperatures were not recorded on the weekends.
In March 2022 the humidity in the OR Room 2 was out of range for 11 of 24 recorded days. The Temperature in the OR Room 2 was out of range for 14 of 24 recorded days. Humidity and temperatures were not recorded on the weekends.
In March 2022 the humidity in the "soft goods" room was out of range for 17 of 24 recorded days. Humidity and temperatures were not recorded on the weekends.
In March 2022 the humidity in the decontamination room was out of range for 14 of 24 recorded days. The Temperature in the decontamination room was out of range for 18 of 24 recorded days. Humidity and temperatures were not recorded on the weekends.
In March 2022 the humidity in the SPD was out of range for 18 of 24 recorded days. The Temperature in the SPD was out of range for 8 of 24 recorded days. Humidity and temperatures were not recorded on the weekends.

In April 2022 the humidity in the OR Room 1 was out of range for 3 of 19 recorded days. The Temperature in the OR Room 1 was out of range for 3 of 19 recorded days. Humidity and temperatures were not recorded on the weekends.
In April 2022 the humidity in the OR Room 2 was out of range for 4 of 14 recorded days. The Temperature in the OR Room 2 was out of range for 11 of 14 recorded days. Humidity and temperatures were not recorded on the weekends.
In April 2022 the humidity in the SPD was out of range for 6 of 21 recorded days. The Temperature in the SPD was out of range for 9 of 21 recorded days. Humidity and temperatures were not recorded on the weekends.
In April 2022 the humidity in the decontamination room was out of range for 4 of 20 recorded days. The Temperature in the decontamination room was out of range for 9 of 20 recorded days. Humidity and temperatures were not recorded on the weekends.
In April 2022 the humidity in the "soft goods" room was out of range for 4 of 21 recorded days. The Temperature in the "soft goods" room was out of range for 3 of 21 recorded days. Humidity and temperatures were not recorded on the weekends.

Documentation on the logs reflected maintenance was contacted at times; however, documentation did not reflect the temperature and humidity were re-checked and the resolution to the problem was not documented.

In an interview with the Surgery Director on 5/24/22, the above out of range humidity and temperatures for each of the rooms above were confirmed. She stated in part "The OR techs monitor the temperatures and humidity in each of the rooms and they are new to their positions. When they are out of range they are expected to contact maintenance. A comment should be made each time they are out of range addressing what action was taken to correct the temperature and/or humidity. Temperatures and humidity are not monitored on the weekends. This is an old building, It is not sealed or insulated well and temperatures and humidity are difficult to manage."

Based on inspection and interview, it was determined that the facility did not always practice good infection control practices.

Findings were:

"OSHA/Bloodborne Pathogen Regulations Policy #138-030-060" stated in part "The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner."

According to FDA Food Code 2009: Annex 3 - Public Health Reasons / Administrative Guidelines - Chapter 4, Equipment, Utensils, and Linens, "4-901.11 Equipment and Utensils, Air-Drying Required: Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils."

Tour of the ED on 5/24/22 revealed dust on high horizontal surfaces and surgical lighting.

Wet pans were found stacked in the kitchen which could lead to bacterial growth.

The inpatient area of the hospital was toured on 5/25/22. Two unoccupied patient rooms were inspected. One bathroom shower was noted to be dirty, with hair on the floor. High horizontal dust was also noted in both rooms. The patient nutrition refrigerator was opened. The freezer had melted popsicles inside.

The above infection control issues were confirmed by the CNO on 5/24 and 5/25/22.