HospitalInspections.org

Based on policy and procedure review and observation during tours in the Operating Room (OR), the staff failed to monitor temperature controlled equipment per hospital policy on 2 of 4 observed units.

The findings include:

Review of the policy Medication Refrigerator/Freezer Temperature last revised 10/09/2012. revealed, "PURPOSE: To establish a procedure for performing and documenting daily refrigerator temperature checks to ensure that normal cooling ranges are maintained. A. The acceptable temperature range for the refrigerator is 2 degrees centigrade to 8 degrees centigrade ( 36 degrees F to 46 degrees F). ...D. The temperature will be documented on the log provided and the log will be maintained in an accessible location. E. If the temperature falls outside the acceptable range, take appropriate action and document action taken on the log. 1. Ensure the door is closed 2. Adjust the thermostat F. If the temperature exceeds the acceptable range or approaching freezing for more than four hours, all drugs must be located to another refrigerator. The designated staff person will tag the refrigerator as defective and staff will not use the refrigerator to store medications until repairs have been made. G. If length of temperature variance is unknown or excessive, call the Pharmacy Department for instructions...".

Review of "Blanket and Fluid Warmer Guidelines: Blanket Warmer.. Staff should check that the temperature indicator does not exceed 54 degrees C (centigrade) (130F) each time a blanket is removed from the warming cabinet....Arthomatic and Uromatic Irrigation Solutions (Sterile H2O, NaCL and Glycine) Solutions can be warmed in their overpouches only to temperature not exceeding 45 degrees C (113F) and for a period no longer than 14 days or 66 degrees C (150F) for a period no longer than 72 hours."

Observation during tour of the OR (operating room suite) on 04/22/15 at 1325 revealed review of the refrigerator temperature check sheet on the the malignant hyperthermia cart refrigerator temperatures were documented as 1.7 degrees centigrade (1.7 C) on 04/7/2015 and 04/8/2015 and < (less than ) 1 degree centigrade (<1C) on 04/14/2015. Review of the temperature check sheet revealed no corrective action documented on any out of range temperatures. Observation during tour in the OR revealed a blanket and fluid warmer temperature check sheet with documented temperatures of 131 degrees Fahrenheit (131F) on 04/05/2015,04/06/2015, 04/18/2015 and 04/20/2015. Review of the blanket and fluid warmer check sheet revealed no corrective action documented on any out of range temperatures.

Interview on 04/22/2015 at 1325 with CRNA (Certified Registered Nurse Anesthetist)Supervisor during tour confirmed the blanket tempertures and the malignant hyperthermia cart refrigerator were not within range and not reported as out of range. Interview confirmed the hospital's policy was not followed for monitoring temperatures of the blanket warmer and malignant hyperthermia cart refrigerator.