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Based on observation, record review, and interview the facility failed to ensure the temperature and humidity in the operating rooms (OR) was maintained at acceptable parameters. This failed practice created a risk for microbial growth and/or infections. Findings:

Temperature and humidity monitoring in the OR's

Random observations in the 2 operating rooms on 8/6-8/13 revealed humidity ranges from 61 to 65% and temperature ranges from 60 to 65 degrees.

Review from 8/6-8/13 of the "HUMIDITY/AMBIENT TEMPERATURE OR 1 and 2 RECORD 2013" logs revealed:

? The OR humidity parameters was "20-60%" and the OR temperature parameters was "68-73 deg. F.";

? Humidity documented as high as 75%;

? Temperatures were as low as 59 degrees;

? In the month of July there were 7 days when no temperatures or humidity were documented for OR's 1 or 2, and during those days 30 surgeries were performed (surgery schedules were provided by the facility);

? There were 39 days from 5/20-8/6/13 where 2 numbers were written for each day but were not specified as to which were the humidity and which were the temperatures;

? At the bottom of the OR 1 and OR 2 record were documented days when maintenance/biomedical was notified the humidity and/or the temperatures were out of range. OR 1 record revealed maintenance/biomedical was notified 5 times and OR 1 record revealed maintenance/biomedical was notified 7 times and on 7/26-27/13 "Monitor out for servicing".

Review on 8/7/13 of the maintenance work orders, provided by the maintenance department, revealed 3 documented work orders from the surgical unit:

? 6/18/13 "HUMIDITY is above 60 in both OR rooms", with 2 surgeries performed in OR 1 and 1 surgery performed in OR 2 that day;

? 6/26/13 "humidity in OR's [in OR 1] is too high", with 2 surgeries performed that day in OR 1 that day; and

? 7/23/13 "Room heats up making it very difficult to operate". Physician #1 had submitted the work request. There were 5 surgeries performed in OR 1 and 3 surgeries performed in OR 2 that day.

During an interview on 8/6/13 at 2:50 pm, when asked who monitors the humidity and temperature monitoring in the OR's Facilities Engineer #1 said the OR staff document it. He further said, "That is a challenge".

During an interview on 8/7/13 at 8:20 am, Staff #2 was asked about the humidity and temperature monitoring in the OR's. Staff #2 said, "I know they've been having a hard time with humidity monitoring." Maintenance also monitors it but their numbers do not match the portable humidity device the OR used. When asked if the staff had a written procedure they follow to get the OR's ready prior to surgeries, Staff #2 said they did not. Staff #2 further said that in the mornings when they get the OR rooms ready for surgeries, they do not clean the rooms because housekeeping does a terminal cleaning the night before. Staff #2 was asked when the humidity was checked and it was out of the parameters would the staff do any cleaning or wiping down of the OR's prior to the surgeries. Staff #2 said they do not wipe down anything prior to the surgeries, even if the humidity level is higher than the parameters. The first surgery cases usually start at 8:00 am. The staff were required to check the humidity and temperatures by 9:00 am.

During an interview, on 8/7/13 at 9:00 am, the Director of Quality and the Infection Preventionist were asked if they ever looked at the logs in the OR that monitor the humidity and the temperature and discussed the inconsistencies. The Director of Quality said, "We need to fix it."

During an interview on 8/7/13 at 2:00 pm, the Director of Nursing confirmed monitoring of the humidity and temperatures in the OR's were a concern.

Per the AORN (Association of PeriOperative Registered Nurse)" Perioperative Standards and Recommended Practices ...High humidity increases the risk of microbial growth in areas where sterile supplies are stored or procedures are performed. Temperature should be maintained between 68-73 degrees within the operating room suite and general work areas in sterile processing."
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Based on observation, interview, and policy review the facility failed to ensure expired biological and drugs were removed prior to their usage or their potential usage. This placed patients at risk for receiving expired medications and nutritional supplement with potentially negative outcomes. Findings:

Acute Care Unit

Observations during the initial tour of the acute care unit on 8/5/13 at 9:45 am revealed:

5 Jevity (nutritional supplement) 250 calorie/8 oz cans, expired 8/1/13;

1 box, almost full, of 25 g needles, expired 7/13;

3 Children's Liquid Acetaminophen, expired 2/28/13; and

4 Children's Liquid Acetaminophen, expired 7/31/13.


During an interview on 8/5/13 during the initial tour of the acute care unit, the Pharmacy Manager confirmed the 7 Children's Liquid Acetaminophen were expired.

During an interview on 8/5/13 during the initial tour of the acute care unit, the Director of Acute Care Services was asked who was responsible for checking outdates for the needles. She said medical supply would check the supply outdates on the acute care unit.

Emergency Department

During the initial tour of the Emergency Department on 8/5/13 at 9:15 am, an observation of a cart with central venous line supplies, located in the large treatment room, revealed 1 vial of .25% Bupivacaine (a local anesthetic) with an expiration date of July 1, 2013.

During an interview with the Pharmacy Manager on 8/6/13 at 2:30 pm, he confirmed that the vial of Bupivacaine in the central line cart was expired and "should not be there".

Review of hospital policy "PCS-127 -Medication Storage" dated 9/16/08, revealed "8. Expired Medications...All expired ...medications are segregated until they are removed from the hospital or destroyed..."
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Based on observation, interview, and record review the facility failed to ensure infection control practices were followed; specifically, items stored under sinks and hand hygiene practices were not followed. These failed practices created the potential for patient transmission of infections. Findings:

Items stored under sinks

Acute care unit

An observation during the initial tour in the acute care unit clean supply room, on 8/5/13 at 9:15 am, revealed a stack of clean folded washcloths under one sink in an enclosed cabinet and an empty coffee carafe under another sink in an enclosed cabinet. Both enclosed cabinets had other miscellaneous items stored in them.

Sterilization room

An observation in the sterilization room on 8/6/13 at 9:00 am revealed the following were under the sink:

? 15 boxes of Daily Air Removal Test - test unit pre-vacuumed steam sterilizer;

? Multiple boxes of Kimwipes EX-L;

? 5 boxes of Attest Rapid Readout Biological Indicators;

? 2 packages of Steam Chemical Integrator;

? 2 boxes of Comply Chemical Indicators;

? 1 Fiber optic light with pink tag that said "Acute Care"; and

? 1 flexible scope

During an interview on 8/6/13 at 3:15 pm Staff #3 was asked if the Infection Preventionist does any rounding's in the sterilizing room. Staff #3 said there was no infection control monitoring being done in the sterilizing room.

PACU (post anesthesia care unit)

An observation on 8/7/13 at 10:50 am in the PACU area revealed the following items were under the sink:

? Boxes of Ziploc bags, gallon and quart sizes;

? Clean folded washcloths;

? Plastic watering can;

? Glass vases;

? Aloe guard Antimicrobial soap;

? Virex spray bottle;

? Liquid air freshener; and

? 1 small plastic squirt bottle labeled "dish soap".

During an interview on 8/7/13 at 10:50 am, Staff #4 was asked what the washcloths under the sink were used for. Staff #4 said they use the washcloths to wipe things down in the PACU area.

During an interview on 8/7/13 at 9:00 am the Infection Preventionist confirmed items should not be stored under sinks.

Hand hygiene

General observations during the survey on 8/5-8/13 revealed 9 outdated Avagard (Trademark) hand disinfectants in the following areas:

Acute care unit soiled utility room, expired 1/13;

Negative pressure room 218 in the acute care unit, expired 7/13;

Acute care unit tub room, expired 11/12;

Kitchen, expired 11/12;

Sterilization room in the surgical suite, expired 2/13;

Operating room 2, expired 2/13;

Outside operating room 2 on the shelf above the sink, expired 11/12 and 2/13; and

In the surgical procedure room, expired 11/12.

Continuous observation on 8/7/13 from 9:45 am - 10:45 am during a procedure for Patient #9 revealed Staff #5 frequently used Avagard (Trademark), which had an expiration date of November 2012.

During an observation on 8/6/13 at 7:55 am in the pre-operative area Staff #6 was preparing to start an IV (intravenous, into the vein) on Patient #8. Staff #6 pulled up lidocaine (a medication used to numb the skin prior to the IV being put into the vein) from a vial into a syringe; used alcohol wipes to prepare the skin; numbed the skin with the lidocaine; and put the IV into the hand area. The IV could not be threaded so Staff #6 took it out and explained to the patient he would have to try again. Staff #6 repeated the process and did put the IV in Patient #8s arm successfully. The whole process was done without Staff #6 wearing gloves.

During an observation on 8/6/13 at 7:55 am in the pre-operative area, Staff #6 inserted an IV on Patient #8. During the process which consisted of giving a subdermal injection (under the skin) of numbing medication, cleaning the arm with an alcohol swab, and inserting the IV into the vein, Staff #6 did not wear gloves.

During a second observation on 8/7/13 at 9:00 am, Staff #6 was observed starting an IV on Patient #6. During the process, which consisted of prepping the Patients skin with alcohol and inserting the IV into a vein, Staff #6 did not wear gloves. After the procedure, Staff #6 picked up something from the floor; documented in the Patient's chart; gave the Patient his call light; and exited the room without washing his hands.

During an interview on 8/8/13 at 9:00 am with the Director of Quality and the Infection Preventionist, they were both asked about staff not using gloves to start IVs. They both confirmed staff need to wear gloves when starting IVs.

Review of the facility policy "HAND HYGIENE" reviewed 5/25/12, revealed "...Hand Hygiene procedures are indicated in the following circumstances...after having contact with any patient ..."

Centers for Disease Control "Healthcare Infection Control Practices Advisory Committee" revealed "...Standard Precautions...Wear disposable medical examination gloves for providing direct patient care."
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