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Based on observation, interview, and record review, the facility failed to ensure a patient's Advance Directive was placed in the patient's record, for one of 35 patients, (Patient 6), which potentially could lead to confusion regarding the patient's right to participate in health care decision making.

Findings:

Patient 6 was observed on January 31, 2012, at 9:30 a.m., lying on his hospital bed. The patient's eyes were closed, he was non verbal, appeared agitated, and was moving about in the hospital bed with non purposeful movements.

A concurrent interview was conducted with the patient's family member who stated the facility was not adhering to the patient's Advance Health Care Directives (document which communicates a patient's health care preferences in advance).

A review of Patient 6's record was conducted. Patient 6 was admitted to the facility on January 5, 2012, with diagnoses of brain damage, end stage kidney disease and diabetes. An Advance Directive Flow Sheet, dated January 5, 2012, indicated Patient 6 has an Advance Directive "on file."

Further record review failed to show an Advance Directive in Patient 6's record, or documentation as to why it had not been placed in the patient's record 25 days after having been acknowledged as being "on file."

A review of the facility policy, "Advance Directives (Revision Date: January 2008)," indicated if an Advance Directive is "on File," the document will be placed in the chart and the nurse will be notified.

An interview was conducted with the Director of Admitting on January 31, 2012, at 3 p.m., who stated if an Advance Directive is "on file," it needs to be placed in the patient's record.

Based on interview and record review, the facility failed to ensure a registered nusre supervised and evaluated nursing care for 2 of 35 sampled patients (Patients 7 and 9) by failing to:

1. Ensure the Medication Reconciliation procedure was followed and the form completed per the facility's policy for Patients 7 and 9 and,

2. Ensure the SBAR (situation, background, assessment, and recommendation) nursing communication form was completed per the facility's policy the patients (Patients 7 and 9) were transferred to other medical units within the facility.

These failures could lead to miscommunication with medication management and the provision of medical care.

Findings:

1. a. A review of Patient 7's record was conducted on January 31, 2012. Patient 7 was admitted to the facility on January 23, 2012, with a diagnosis of heart failure. During her hospitalization, the patient was transferred between the telemetry and definitive observation units to accommodate her medical needs.

A review of the Medication Reconciliation form dated January 23, 2012, indicated Patient 7's medications were not reconciled (the process of comparing a patient's medication orders to the medications that the patient is currently taking) when the patient was transferred to the telemetry unit on January 27, 2012, when she was transferred to the definitive observation unit on January 28, 2012, and when she returned to the telemetry unit on January 30, 2012.

b. A review of Patient 9's record was conducted on January 31, 2012. Patient 9 was admitted to the facility on December 31, 2011, with diagnoses of sepsis (infection), and diabetes. The patient was transferred from the intensive care unit to the definitive observation unit on January 16, 2012, and to the telemetry unit on January 25, 2012, to accommodate his medical care needs. There was no documentation found to indicate the patient's medications were reconciled during these transfers.

An interview was conducted with the Charge Nurse (CN 1) on January 31, 2012, at 11 a.m., who stated all medications were to be reconciled when a patient is transferred to another unit within the facility.

A review of the facility's pharmacy and nursing policy, "Medication Reconciliation, (Reviewed: 5/10)," indicated, "...This reconciliation is done to avoid medication errors such as omissions, duplication, dosing errors, or drug interactions. It should be done at every transition of care in which new medication orders are ordered or existing orders are rewritten...The reconciliation process will be completed upon the initial assessment, upon transfer, and at the time of discharge."

The Medication Reconciliation form is composed of columns which will be checked upon admission, transfer(s,) and upon discharge to indicate if a medication is to be stopped or continued. The policy further indicated, at the time of discharge, the nurse will use the Medication Reconciliation form to generate the most accurate list of medications to use for the patient's discharge instructions. The form is then signed by the nurse to indicate that the medications have been reconciled.

An interview was conducted with the Pharmacy Director on January 31, 2012, at 2 p.m., who stated, completion of the Medication Reconciliation Form has been a problem.

2. A review of Patient 7's record was conducted on January 31, 2012. Patient 7 was admitted to the facility on January 23, 2012, with a diagnosis of heart failure. The patient was transferred between the telemetry and definitive observation units to accommodate her medical care needs.

A review of Patient 9's record was conducted. Patient 9 was admitted to the facility on December 31, 2011, with diagnoses of sepsis (infection), dehydration and diabetes. The patient was transferred between the definitive observation unit, the intensive care unit, and the telemetry units to accommodate his medical care needs.

A review of the facility's nursing policy, "In-House Transfer Of Patient, (Revision Date: June 2011)," was conducted. The policy indicated when an in house transfer of a patient occurs, the SBAR document must be used. "The nurse transferring the patient is responsible for completing the SBAR form...This form is an official chart form and must be filed under the initial assessment tab in the patient's chart."

Further record review failed to show the SBAR communication form in Patient 7 and 9's record.

An interview was conducted with the Director of the Intensive Care Unit on January 31, 2012, at 2 p.m., who stated the SBAR transfer note should be used when patients are transferred from one unit to another. The SBAR transfer document was not used for Patients 7 and 9.

Based on interview and record review, the facility failed to ensure the Interdisciplinary Care Plans, regarding diabetic management and discharge planning, was individualized to meet the patients medical needs, which potentially led to an unsafe and fragmented discharge, resulting in the patient's readmission to another acute facility within 24 hours of discharge for one of 35 patients, (Patient 8).

Findings:

A review of Patient 8's record was conducted on February 1, 2012. Patient 8 was admitted to the facility on September 10, 2011, with diagnoses of pneumonia, diabetes, lung disease, morbid obesity and heart failure. Patient 8 was discharged on October 12, 2011.

The physician orders dated October 11, 2011, at 3:50 p.m., indicated, "Okay to discharge patient to B&C (board and care) facility now."

An interview was conducted with the Director of Case Management (DCM) on February 1, 2012, at 10:20 a.m. The DCM stated the physician's discharge order regarding Patient 8 was not implemented as the patient was not discharged to a B&C facility, but was discharged to a room and board.

The DCM stated the patient's discharge to a room and board was equivalent to a discharge home without assistance, where a person must be independent with self care and with their medical care, whereas a board and care is a licensed facility with licensed staff which can assist the patient.

An interview was conducted with the Medical Social Worker on February 2, 2012, at 9 a.m., who stated one reason the assisted living facility where Patient 8 lived prior to his hospitalization would not accept Patient 8 was due to "non compliance with his self care."

A review of the facility policy, "Interdisciplinary Care Plan (Reviewed 6/11)," was conducted. The purpose indicated, "To ensure that the planning of care and delivery of services is individualized to meet the patients needs, and provided in an interdisciplinary collaborative manner, as appropriate to each patient...For each active problem identified, a specific and measurable intervention, goal and target date will be established."

A review of the Interdisciplinary Care Plan for Patient 8 was conducted. There was no documentation on the care plan which specifically addressed the patient's diabetes, and educational needs related to his diabetes, such as monitoring of blood sugar levels (with return demonstrations of the skill), signs and symptoms of low and high blood sugar levels, and how to use a glucometer (machine which monitors blood sugar levels), and administer insulin (medication which regulates blood sugar levels).

A review of the facility's case management policy, "Discharge Planning (Revision Date: March 2010," indicated, "All discharge plans are documented on the multidisciplinary care plan. All disciplines provide input to the care plan as necessary through the coordination of the case manager."

Further review of the Interdisciplinary Care Plan for Patient 8 was conducted. There was no documentation in the care plan which specifically addressed the patient's individualized discharge needs, including equipment needs upon discharge, such as a glucometer and insulin syringes, and locating a safe and appropriate discharge location, and to refer the patient for home health services.

There was not an individualized care plan which addressed the patient's specific non compliance with his medical care needs.

An interview was conducted with RN 8 on February 2, 2012, at 9:15 a.m., who stated if a patient has diabetes, a care plan must be developed to address their diabetes, to include education, such as a review of signs and symptoms of high and low blood sugar levels, and return demonstrations of how to use a glucometer and administration of insulin.

There was no documentation found to indicate return demonstrations of how to use a glucometer and administration of insulin were conducted.

An interview was conducted with the DCM on February 1, 2012, at 10:45 a.m., who stated Patient 8 was discharged to a room and board without medications or prescriptions, without a glucometer which could have been supplied by our facility.

The DCM also stated the patient was discharged without home health support to assist with diabetic management and other medical needs as indicated.

The DCM stated the facility received a call from an acute care facility on October 13, 2011, stating the patient was transferred to their facility via ambulance.

Based on observation, interview, and record review, the facility failed to ensure the competency of two Licensed Vocational Nurses (LVN 1 and LVN 2). The LVN's were allowed to work in the Mother/Baby Unit prior to demonstrating competency. Also, LVN 2 did not have current annual competencies completed for the med/surg unit. These failures could result in inappropriate nursing care and treatment.

Findings:

1. On January 31, 2012, at 9 a.m., LVN 1 was observed working in the Mother/Baby Unit.

In a concurrent interview with the Charge Nurse (CN 2), she stated LVN 1 was a nurse from the Med/Surg Unit, and occasionally "floated" to the Mother/Baby unit. CN 2 stated LVN 1 was caring for the mothers only because she did not possess an NRP (certificate which indicates the recipient is trained in neo-natal resuscitation) that was required to care for babies.

On January 31, 2012, at 2:40 p.m., LVN 1 was interviewed. LVN 1 stated she worked primarily on the Med/Surg Unit, but floated to other areas of the hospital, including the Mother/Baby unit. LVN 1 stated she has worked at the facility for eight years, and completed the annual competencies for Med/Surg each year. LVN 1 stated she thought if she did the Med/Surg competencies then she was able to float anywhere in the hospital. LVN 1 further stated that she did not remember ever doing any unit specific competencies for the Mother/Baby unit.

On February 1, 2012, the employee file for LVN 1 was reviewed. There was no documentation that indicated LVN 1 demonstrated unit specific competencies for the Mother/Baby Unit prior to working there.

2. The January 2012, the Mother/Baby Staffing Sheets for the Mother/Baby Unit were reviewed on February 2, 2012. The staffing sheets indicated LVN 2 was floated to the Mother/Baby unit on January 12 and 13, 2012.

On February 1, 2012, the employee file for LVN 2 was reviewed. There was no documentation that indicated LVN 2 demonstrated unit specific competencies for the Mother/Baby Unit prior to working there. In addition, the last Med/Surg annual competencies and performance evaluation was completed in August 2010.

On February 1, 2012, at 3:30 p.m., the Human Resources (HR) Director was interviewed. The HR Director stated any staff floating to another unit of the hospital must first demonstrate competencies for that unit prior to working there, and documentation of those competencies are to be in the employee file.

The employee files for LVN 1 and LVN 2 were also reviewed with the HR Director. The HR Director stated LVN 1 and LVN 2 did not have the unit specific competencies for the Mother/Baby unit prior to working there. She stated both LVNs were not on the list of nurses that floated to that unit and therefore it was not initiated. In addition, the HR Director stated LVN 2 should have completed her annual competencies and performance evaluations in August 2011 for the Med/Surg unit. She stated, "it was missed."

The P&P titled, "Floating," dated June 2011, was reviewed. The policy indicated, "All nurses are to float to areas where they have demonstrated competency."

The P&P titled, "Nursing Competencies and Education Requirements,"dated January 2008, was reviewed. The policy indicated, "All nursing service employees who have completed their new employee orientation/introductory period participate annually in competency reassessments."

The P&P titled, "Competency Process,"dated May 2007, was reviewed. The policy indicated, "Competencies are considered delinquent if they are not completed and returned to Human Resources within thirty (30) days of the due date.

Based on interview and record review, the facility failed to ensure medication orders were written in accordance with standards of practice and the facility policy for one of 35 sampled patients (Patient 17). This failure had the potential to result in medication administration error.

Finding:

On January 31, 2012, Patient 17's record was reviewed. Patient 17 was admitted to the "Admit Unit" for Definitive Observation Unit (DOU) level of care.

The physician's orders dated January 31, 2012, at 5:30 a.m., were reviewed and included:

a. "Reglan 5 mg IVP (intravenous push) Q (every) 6 hrs (hours) N/V (nausea and vomiting)"
b. "Cardizem 10 mg Q 20 minutes for hr (heart rate) over 120 (beats per minute)"
c. "Tylenol 650 mg po (by mouth) prn (as needed) pain or temp."

Patient 17's record did not contain documented evidence that the medications were clarified with the prescribing physician.

The Medication Activity Record (MAR) was reviewed and indicated:

a. "Reglan 5 mg IVP Q 6 hrs PRN - N/V"
b. "Cardizem 10 mg IV Q 20 mins PRN for HR > (greater than) 120 (beats per minute)"
c. "Tylenol 650 mg po Q 6 hrs PRN for pain or temp."

On January 31, 2012, at 11:30 a.m., Patient 17's record was reviewed with RN 1. RN 1 stated when medication orders were written incompletely, the physician is called to clarify the orders. RN 1 stated the medication orders and the MAR needed to match. RN 1 verified the following:

a. Reglan order was missing the "PRN";
b. Cardizem order was missing the route of administration - "IV"; and
c. Tylenol order was missing the frequency - "Q 6 hours."

On January 31, 2012, the facility policy titled, "Administration of Medications," dated May 2010, was reviewed. The policy indicated, "...Orders for medication shall include the name of the drug, the dosage, the frequency of administration, the route of administration, if other than oral, indication for use for all prn medications..."

Based on observation, interview, and record review, the facility failed to ensure surgical services were provided in accordance with acceptable standards of practice, designed to assure and maintain high standards of patient care by:

1. Failing to maintain temperature and relative humidity levels within acceptable ranges, in accordance with current AORN Standards (Association of periOperative Registered Nurses - a nationally recognized organization) and federal statutes in the operating and procedure rooms (refer to A951);

2. Failing to develop, maintain, and implement facility policy(s) that followed current AORN Standards and federal statutes in the operating and procedure rooms in monitoring temperature and relative humidity readings in order for the facility to identify any concern(s) that would require corrective actions (refer to A951); and

3. Failing to follow AORN Standards, by using portable and freestanding humidifiers in the operating rooms (refer to A951).

These failures had the potential to result in the operating and procedure rooms' environment to be at a higher risk for fire and/or burn to the environment and/or the patient. In addition, this resulted in the operating and procedure rooms' environment to be at higher risk for growth of microorganisms and aerosolize (diffuse) these microorganisms into the clean environment, which may result in patient infection.

The cumulative effects of these systemic problems resulted in the failure of the perioperative department to provide a surgical environment in a manner that ensured the health and safety of all patients.

Based on observation, interview, and record review, the facility failed to ensure surgical services were designed to assure and maintain high standards of patient care by:

1. Failing to maintain temperature and relative humidity levels within acceptable ranges, in accordance with current AORN Standards (Association of periOperative Registered Nurses - a nationally recognized organization) and federal statutes in the operating and procedure rooms;

2. Failing to develop, maintain, and implement facility policy(s) that followed current AORN Standards and federal statutes in the operating and procedure rooms in monitoring temperature and relative humidity readings in order for the facility to identify any concern(s) that would require corrective actions; and

3. Failing to follow AORN Standards, by using portable and freestanding humidifiers in the operating rooms.

These failures had the potential to result in the operating and procedure rooms' environment to be at a higher risk for fire and/or burn to the environment and/or the patient. In addition, this resulted in the operating and procedure rooms' environment to be at higher risk for growth of microorganisms and aerosolize (diffuse) these microorganisms into the clean environment, which may result in patient infection.

Findings:

According to AORN 2011, the temperatures and relative humidity needed to be:

- Relative humidity within perioperative suites including operating rooms, recovery area, endoscopy rooms, instrument processing areas should be maintained between 30 to 60 % and

- Operating room suite and general work areas in sterile processing temperatures should be between 68 to 73 ?F.

According to the NFPA 101 (Federal Statutes) Life Safety Code Standard, "Anesthetizing locations are protected in accordance with NFPA 99, Standard for Health Care Facilities (b) Relative humidity is maintained equal to or greater than 35% (K 078)."

1. On February 1, 2012, at 9 a.m., a tour of the perioperative department was conducted.

The January 2012 temperature and relative humidity log was reviewed, and indicated RH ranges were monitored daily and should be at 20 to 60 % and the temperature ranges should be at 68 to 75 ?F.

The logs from October 2011 through January 2012 were reviewed and indicated the following:

October 2011
a. OR 1 had 11 of 31 days with RH readings greater than 60 % (61 to 64 %);
b. OR 2 had seven of 31 days with RH readings greater than 60 % (61 to 68 %);
c. OR 3 had 27 of 31 days with RH readings greater than 60 % (62 to 75 %);
d. OR 4 had nine of 31 days with RH readings greater than 60 % (61 to 64 %); and
e. Cystoscopy Procedure Room had 25 of 31 days with RH reading greater than 60 % (61 to 69 %).

November 2011
a. OR 1 had four of 30 days with RH readings greater than 60 % (61 to 64 %);
b. OR 2 had five of 29 days with RH readings greater than 60 % (61 to 65 %);
c. OR 3 had two of 30 days with RH readings greater than 60 % (66 and 72 %);
d. OR 4 had one of 30 days with a RH reading greater than 60 % (62 %); and
e. Cystoscopy Procedure Room had 13 of 30 days with RH reading greater than 60 % (61 to 70 %)

December 2011
a. OR 1 had nine of 31 days with RH readings less than 35 % (21 to 31 %);
b. OR 2 had eight of 31 days with RH readings less than 35 % (23 to 34 %);
c. OR 3 had 12 of 31 days with RH readings greater than 35 % (18 to 34 %) and one of 31 days with a RH reading of 61%;
d. OR 4 had seven of 31 days with RH readings less than 35 % (23 to 34 %); and
e. Cystoscopy Procedure Room had four of 31 days with RH reading less than 35 % (30 to 32 %).

January 2012
a. OR 1 had 13 of 31 days with RH readings less than 35 % (23 to 33 %);
b. OR 2 had 12 of 31 days with RH readings less than 35 % (21 to 34 %);
c. OR 3 had 11 of 31 days with RH readings less than 35 % (17 to 33 %);
d. OR 4 had 13 of 31 days with RH reading less than 35 % (21 to 34 %); and
e. Cystoscopy Procedure Room had one of 31 days with a RH reading less than 35 % (32 %).

On February 1, 2012, at 9:25 a.m., the DPS was interviewed and stated the RH range is kept at 20 to 60 % in the perioperative areas. A perioperative staff obtained the RH approximately every 6:30 a.m. (before any case/procedure) and recorded in the log. If any reading was out of range, a work order is placed for plant operations staff to check the area of concern.

On February 1, 2012, at 11:20 a.m., the OR RH logs were reviewed with the DPO. The DPO brought records titled, "Daily Engineering Rounds" to compare with the OR staff's log. The facility was not able to provide documented evidence that action and resolution of the RH out of range readings was completed for seven of eight days randomly selected for review. The facility record indicated the following:

a. October 19, 2011 - ORs 1, 2, 3, 4, and Cystoscopy Rooms' RH readings were greater than 60 % and corrective action was taken on October 28, 2011, with no documented results of action;

b. October 20, 2011 - ORs 1, 2, 3, and Cystoscopy Rooms' RH readings were greater than 60 % and no documented evidence of corrective action was taken;

c. October 21, 2011 - ORs 1, 2, 3, 4, and Cystoscopy Rooms' RH reading were greater than 60 % and no documented evidence of corrective action was taken;

d. November 24, 2011 - OR 1 and Cystoscopy Rooms' RH readings were greater than 60 % and no documented evidence of corrective action was taken;

e. December 23, 2011 - The OR's log indicated all four ORs and Cystoscopy Room had a RH reading less than 35 % and indicated "Engineering notified." The "Daily Engineering Rounds" indicated both ORs 1 and 2 had a RH reading of 34 %. No documented evidence that further corrective action was taken;

f. January 28, 2012 - ORs 1, 2, 3, and 4's RH readings were less than 35 %. The "Daily Engineering Rounds" indicated, "OR Humidity under 30 %." There was no documented evidence of the issue being resolved; and

g. January 29, 2012 - ORs 1, 2, 3, and 4's RH readings were less than 35 % and no documented evidence of the RH problem being resolved.

In a concurrent interview with the DPO, he was unable to provide documented evidence that Plant Operations staff consistently acted upon and resolved the RH readings, which were out of range in the ORs and Cystoscopy Room.

On February 1, 2012, during review of the temperature logs in ORs 1, 2, 3, 4, and Cystoscopy Room, it indicated:

a. October 2011 - 31 of 31 days for all rooms had temperature readings below 68 ?F;

b. November 2011 - 28 of 30 days for all rooms had temperature readings below 68 ?F;

c. December 2011 - 31 of 31 days for all rooms had temperature readings below 68 ?F; and

d. January 2012 - 29 of 31 days for all rooms had temperature readings below 68 ?F.

On February 1, 2012, at 9:40 a.m., the DPS was interviewed and stated the room temperatures (ORs 1, 2, 3, 4, and Cystoscopy Room) were taken early in the morning before the surgeries or procedures began. The DPS added the room temperature increases due to the use of equipment and the number of staff in the room. When the temperature reading was below the acceptable range, Plant Operations was not notified.

On February 1, 2012, the ORs and Procedure Room temperature logs were reviewed. The facility was not able to provide documented evidence that action and resolution of the out of range temperature readings was completed for seven of eight days randomly selected for review.

On February 2, 2012, at 2:45 p.m., the temperature and RH logs were reviewed with the POS. The POS stated he does the temperature and RH reading checks at times. He stated there should be documentation of actions taken, including the results of actions during the days the temperature and/or RH were out of range.

On February 1, 2012, the facility policy titled, "Operating Room Temperature and Humidity," dated September 2010, was reviewed and indicated, "Acceptable temperature range is 68-75 degrees F. Acceptable humidity range is 20-60 %...All temperatures and/or humidity levels out of the acceptable ranges will be reported to engineering via an e-mail work-orders and noted on the log by the person reporting." The policy did not indicate actions or steps to be taken thereafter.

2. According to AORN 2011, the relative humidity within perioperative suites including operating rooms, recovery area, endoscopy rooms, instrument processing areas should be maintained between 30 to 60 %.

According to the NFPA 101 (Federal Statutes) Life Safety Code Standard, "Anesthetizing locations are protected in accordance with NFPA 99, Standard for Health Care Facilities (b) Relative humidity is maintained equal to or greater than 35% (K 078)."

On February 1, 2012, at 9 a.m., a tour of the perioperative department was conducted.

The January 2012 relative humidity log was reviewed and indicated ranges were monitored daily and needed to be at 20 to 60 %.

The logs from October 2011 through January 2012 were reviewed and indicated the following:

October 2011
a. OR 1 had 11 of 31 days with RH readings greater than 60 % (61 to 64 %);
b. OR 2 had seven of 31 days with RH readings greater than 60 % (61 to 68 %);
c. OR 3 had 27 of 31 days with RH readings greater than 60 % (62 to 75 %);
d. OR 4 had nine of 31 days with RH readings greater than 60 % (61 to 64 %); and
e. Cystoscopy Procedure Room had 25 of 31 days with RH reading greater than 60 % (61 to 69 %).

November 2011
a. OR 1 had four of 30 days with RH readings greater than 60 % (61 to 64 %);
b. OR 2 had five of 29 days with RH readings greater than 60 % (61 to 65 %);
c. OR 3 had two of 30 days with RH readings greater than 60 % (66 and 72 %);
d. OR 4 had one of 30 days with a RH reading greater than 60 % (62 %); and
e. Cystoscopy Procedure Room had 13 of 30 days with RH reading greater than 60 % (61 to 70 %)

December 2011
a. OR 1 had nine of 31 days with RH readings less than 35 % (21 to 31 %);
b. OR 2 had eight of 31 days with RH readings less than 35 % (23 to 34 %);
c. OR 3 had 12 of 31 days with RH readings greater than 35 % (18 to 34 %) and one of 31 days with a RH reading of 61%;
d. OR 4 had seven of 31 days with RH readings less than 35 % (23 to 34 %); and
e. Cystoscopy Procedure Room had four of 31 days with RH reading less than 35 % (30 to 32 %).

January 2012
a. OR 1 had 13 of 31 days with RH readings less than 35 % (23 to 33 %);
b. OR 2 had 12 of 31 days with RH readings less than 35 % (21 to 34 %);
c. OR 3 had 11 of 31 days with RH readings less than 35 % (17 to 33 %);
d. OR 4 had 13 of 31 days with RH reading less than 35 % (21 to 34 %); and
e. Cystoscopy Procedure Room had one of 31 days with a RH reading less than 35 % (32 %).

On February 1, 2012, at 9:25 a.m., the DPS was interviewed and stated the RH range is kept at 20 to 60 % in the perioperative areas. A perioperative staff obtained the RH approximately every 6:30 a.m. (before any case/procedure) and recorded in the log. If any reading was out of range, a work order is placed for plant operations staff to check the area of concern.

On February 1, 2012, at 11:20 a.m., the OR RH logs were reviewed with the DPO. The DPO brought records titled, "Daily Engineering Rounds" to compare with the OR staff's log. The facility was not able to provide documented evidence that action and resolution of the RH out of range readings was completed for seven of eight days randomly selected for review. The facility record indicated the following:

a. October 19, 2011 - ORs 1, 2, 3, 4, and Cystoscopy Rooms' RH readings were greater than 60 % and corrective action was taken on October 28, 2011, with no documented results of action;

b. October 20, 2011 - ORs 1, 2, 3, and Cystoscopy Rooms' RH readings were greater than 60 % and no documented evidence of corrective action was taken;

c. October 21, 2011 - ORs 1, 2, 3, 4, and Cystoscopy Rooms' RH reading were greater than 60 % and no documented evidence of corrective action was taken;

d. November 24, 2011 - OR 1 and Cystoscopy Rooms' RH readings were greater than 60 % and no documented evidence of corrective action was taken;

e. December 23, 2011 - The OR's log indicated all four ORs and Cystoscopy Room had a RH reading less than 35 % and indicated "Engineering notified." The "Daily Engineering Rounds" indicated both ORs 1 and 2 had a RH reading of 34 %. No documented evidence that further corrective action was taken;

f. January 28, 2012 - ORs 1, 2, 3, and 4's RH readings were less than 35 %. The "Daily Engineering Rounds" indicated, "OR Humidity under 30 %." There was no documented evidence of the issue being resolved; and

g. January 29, 2012 - ORs 1, 2, 3, and 4's RH readings were less than 35 % and no documented evidence of the RH problem being resolved.

In a concurrent interview with the DPO, he was unable to provide documented evidence that Plant Operations staff consistently acted upon and resolved the RH readings, which were out of range in the ORs and Cystoscopy Room.

On February 1, 2012, the facility policy titled, "Operating Room Temperature and Humidity," dated September 2010, was reviewed and indicated, "...Acceptable humidity range is 20-60 %...All...humidity levels out of the acceptable ranges will be reported to engineering via an e-mail work-orders and noted on the log by the person reporting."

On February 1, 2012, the OB OR logs were reviewed and indicated acceptable RH ranges of 35 to 60 %.

On February 1, 2012, at 9:25 a.m., the DPS was interviewed and stated change in the RH range of 20 to 60 % was determined from literature reviewed by the facility's Quality Council. The literature was based on "AORN Management Connections," dated May 2010. The literature indicated, "...AORN's current Recommended Practices for a Safe Environment of Care updated in November 2009 will be revised to reflect these new recommended relative humidity levels (20 to 60 %), but the date of the future revision has not yet been scheduled..."

On February 1, 2012, at 12 p.m., current AORN recommendations (published 2011) were reviewed with the CNO. The CNO agreed the current recommendations for OR RH ranges were 30 to 60 %. The CNO acknowledged current NFPA requirements indicate RH in the ORs needed to be greater or equal to 35 %.

3. On February 1, 2012, at 2 p.m., during a tour of the perioperative areas, the following areas had portable free-standing humidifiers: ORs 1, 2, and the Sterile Processing Department (SPD). In a concurrent interview with the OMC, he stated the facility used the humidifiers when the RH ranges were low. The DPS and DPO both stated the facility did not have any policy permitting or forbidding the use of humidifiers.

On February 2, 2012, at 3:15 p.m., the CNO was interviewed and stated the facility did not have a policy on the use of humidifiers in the perioperative areas.

According to 2011 AORN recommendations, "Free-standing humidifiers should not be used because they can harbor microorganisms in fluid reservoirs and aerosolize these microorganisms into the clean environment...Free-standing fans, humidifiers, or dehumidifiers should not be used in the operating room or sterile processing areas...Free-standing fans can disrupt the air-flow patterns, resulting in contamination of the sterile field..."