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Based on the survey findings it was determined the Condition of Participation for Surgical Services 482.51 was not met. The facility failed to maintain humidity levels in three (3) of four (4) Operating Rooms (OR # 1. #2, and #3) within the acceptable range of 30-60 % to ensure patients received care in a safe environment. Upon knowledge that the humidity levels were not within the acceptable range, the facility began to monitor the temperatures and humidity levels. However, the facility could not control the humidity levels and continued to perform surgeries in OR #1, #2, and #3 with high humidity levels, placing patients at risk for infections.

In addition, the facility failed to develop a policy or procedures with specific parameters in regard to when an OR suite would be closed and surgeries re-scheduled due to high humidity levels that the facility could not control.
Refer to A-951

Based on observation, staff interviews, and review of the Operating Room (OR) temperature and humidity log, facility policy, and 2012 Edition of Association of Operating Room Nurses (AORN) Preoperative Standards and Recommended Practices for Inpatient and Ambulatory Settings, it was determined the facility failed to maintain the humidity levels in three (3) of four (4) OR suites (#1, 2, & 3) to ensure patients received care in a safe environment.

Interview and record review revealed the thermostat in OR suite #1 was broken from July 1, 2012-August 8, 2012. The facility could not measure temperature and humidity in that suite therefore, nothing was recorded for July 2012. Review of the temperature and humidity log for OR suites #2, #3, and #4 revealed relative humidity levels (RH) above the acceptable range of 30-60%, multiple days in July and August 2012. The facility had recorded the high humidity levels; however, the facility failed to implement a plan of action that would reduce the high humidity levels and surgeries were still being performed in those OR suites. The facility began to monitor the recorded temperatures and humidity levels on 08/08/12. Review of the recorded temperature and humidity levels for OR #1, 2, 3, and #4 (during the complaint survey August 15-16, 2012) revealed the facility was unable to maintain humidity levels within the acceptable range of 30-60% for OR #1, #2, and #3 due to a failure of the older pneumatic air system. (OR #4 is newer and is on a computerized electronic system). Although the facility had knowledge that the system could not maintain humidity levels within the acceptable 30-60% range, the facility failed to develop policy and procedures with parameters to detail when the facility would consider closing the OR suites that had humidity readings outside the acceptable range to ensure patients received care in a safe environment without the risk for infections.

The findings include:

Review of the 2012 edition of the AORN revealed established recommend practices to reflect the acceptable relative humidity ranges of 30-60% and temperatures ranges of 68-73 degrees Fahrenheit (F). The 2012 edition of AORN revealed high humidity levels increased the risk for microbial growth in areas where surgery or procedures are performed. The facility stated they used the AORN guidelines.

Review of the facility's policy regardng preparing the OR environment, revised 10/08/11, revealed the OR staff are to monitor the OR's temperature and humidity levels. A room temperature between 68-73 degrees F inhibits bacterial growth. A relative humidity of 30-60% facilitates decreased bacterial growth and static electricity.

1. Observation of OR #1, on 08/15/12 at 10:05 AM, revealed a temperature reading of 68 degrees F. and a humidity level of 62%. The log for OR #1 had the following readings: 08/09/12 air temperature reading of 66 degrees F and 62% humidity. On 08/13/12, recorded readings of 63 degrees F and 66% relative humidity. On 08/14/12, temperature readings of 63 degrees F and 69% humidity and on 08/15/12, a temperature reading of 64 degrees F and 66% humidity was recorded.

2. Observation of OR #2, on 08/15/12 at 10:10 AM,, revealed temperature readings of 66.8 degrees F and 62 relative humidity. Review of the log revealed temperatures and humidity levels were recorded for August 9, 13 th, 14 th, and 15 th. The temperature range was 65-69.7 degrees F. Recorded humidity levels were 64%, 61%, 64%, and 65%.

3. Observation of OR #3, on 08/15/12 at 10:15 AM, revealed a temperature of 66 degrees F and humidity level of 62%. Review of the log revealed temperatures and humidity recorded for August 9, 13 th, and 15 th. The recorded temperatures were all 66 degrees F and humidity levels were recorded to be 59%, 61%, and 60%.

Review of the OR temperature and humidity log for July 2012 revealed OR #1 had no recordings. OR #2 had only fourteen (14) days recorded with humidity level above 60 (63-72) on all 14 days. OR #3 had 14 days recorded with only two (2) days with humidity levels above 60. Review of the August log revealed OR #2 had humidity readings above 60 for six (6) of seven (7) days.

OR suite #4 is a computerized electronic system that obtain readings every 15 minutes and will alarm if outside the acceptable parameters set by the facility. Those parameters are temperatures of 68-73 degrees F and humidity levels of 30-60%.

4. Observation of OR #4, on 08/15/12 at 1:30 PM, revealed two servicemen obtaining manual readings for relative humidity levels (using a hand held device) to compare to the readings from the thermostat in the four (4) OR suites. The workers shared readings they obtained. In OR #1, the manual reading for the humidity was found to be 66% instead of the 60% recorded. In OR #2, the manual reading was 62%, and OR #3 the relative humidity reading was 62%.

Continued review of the OR temperature and humidity log for August 2012 revealed no readings for OR #1 from 07/01/12-08/08/12.

Interview with the Director of Surgical Services, on 08/15/12 at 10:30 AM, revealed the thermostat in OR #1 was broken for the entire month of July and was replaced on 08/08/12. An environmental aide was supposed to obtain temperatures and humidity levels in each OR prior to any surgery for that day. He stated he assumed the aide had obtained and recorded the temperature and humidity. He had not reviewed the logs to ensure the temperatures and humidity were within the acceptable range of 30-60%. Once he became aware of the problem, a new thermostat was placed in OR #1 and he had developed a new monitoring tool that included a place to document what actions were taken to correct the problem. The Director stated the humidity levels remained high in OR #1, #2, and #3. When asked about the temperatures, he stated the physician liked the OR to be cool and would turn the thermostat down. He indicated this problem had not been addressed. When asked if he would ever consider closing the OR that had high relative humidity readings, the Director indicated he would but could not give any specific parameters that he would follow. He revealed the facility did not close any OR suite for the month of July 2012 or August 2012 even though the relative humidity levels were greater than the acceptable 30-60%.

Interview with the Director of Maintenance, on 08/15/12 at 4:30 PM, revealed OR #4 is the only room that is computerized with the capacity to monitor the temperatures and humidity electronically. This computer system would alarm whenever the temperatures and humidity levels were out of range. OR #1, #2, and #3 are on a pneumatic system that is not connected to the computer system. Therefore, the OR staff must take temperature and humidity readings manually from the thermostat on the wall. He stated he was just recently informed of the problems with relative humidity levels in OR #1, #2, or #3. He stated a problem with the older pneumatic air system with floating debris was identified. He found the chillers, boiler, and air handlers were working properly; however, due to the floating debris, he was unable to maintain acceptable humidity levels in those OR suites. Although the Director of Surgical Services had notified him of the continuation of high humidity levels in OR #1, #2 and #3, he indicated the facility did not have full control of the system at this time and could not get the humidity levels down to acceptable levels. He stated he did not have control of the thermostats in OR #1, #2, and #3, therefore, the OR staff could increase or decrease the temperatures. He acknowledged the room temperatures had been below the recommended 68-73 degrees F. When asked if the facility ever closed an OR, he stated not to his knowledge; however, he would not be the person making that decision.

Interview with the Chief Nursing Officer, on 08/15/12 at approximately 5:30 PM, revealed she had just became aware of the relative humidity problems in OR #1, #2, and #3. She stated corporate had been notified and was providing resources to assist the facility. When asked if she would consider closing an OR that had humidity readings outside the acceptable 30-60%, she said, Yes. However, she did not provide specific guidelines or parameters to guide the facility in that decision. In addition, there was no policy or procedures regarding when to close the OR to ensure patients' safety.

Review of the surgical infection log revealed one post-op surgical infection was recorded for July 2012. There was no available data for August 2012.