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Based on document review, observation and interviews it was determined the facility failed to track, trend and or analyze the effects of decreased operating room temperatures and increased operating room humidity readings for 4 of 4 operating rooms to ensure the safety of patients during surgical procedures.

Findings Include:

On 10/18/2013 a tour of the Surgical Suite revealed 4 operating rooms (OR). A request for the Temperature and Humidity log book for the monitoring of the operating rooms could not be produced at the time of the survey.

A review of the facility policy titled "Temperature and Humidity Air Exchange Monitoring", Effective 08/1994, Reviewed 11/2011, Revised 01/2013-[Reference: AORN (Association of periOperative Registered Nurses) Standards Practice Guidelines, Safe Environment of Care]. states: "Temperature and humidity levels in each operating room will be monitored and recorded each day shift normally staffed (i.e., Monday - Friday, excluding holidays). Each log sheet is to be used for one month. Log sheets are to be kept in the Temperature/Humidity Log Book in the OR".

A review of the computerized temperature and humidity log (supplied by bio-medical engineering) was reviewed for April 1st to October 18, 2013. It revealed Operating Room #2 was not reporting and had not reported since July 02, 2013. The computerized temperature and humidity readings for operating rooms #1, #3 and #4 revealed out of range temperatures below the minimum standard of 68 degrees Fahrenheit and out of range relative humidity readings above the maximum standard of 60 percent established by facility policy titled "Temperature and Humidity Air Exchange Monitoring", Effective 08/1994, Reviewed 11/2011, Revised 01/2013-[Reference: AORN (Association of periOperative Registered Nurses) Standards Practice Guidelines, Safe Environment of Care].

On 10/18/2013 at approximately 5:00 p.m. an interview with the Manager of Biomedical Engineering regarding the monitoring of the temperature and humidity levels in the Operating Rooms revealed the facility uses a computerized system for collecting humidity and temperature data in each of the four ORs. The computerized reports displayed hourly temperature and humidity data collected for OR #1, #3 and #4 for the requested date range of April 1, 2013 to October 18, 2013. He stated the data for OR #2 was not available due to the computerized system failing to collect data since July 3, 2013. He stated he first became aware the system was not functioning properly in OR #2 at approximately 3:00 p.m. on October 18, 2013 when he was requested to run the reports. He stated he does not routinely run or monitor temperature and humidity reports generated by the computerized system as this was the responsibility of the OR staff. He stated the temperature devices are calibrated once annually, but he does not know of any calibration methods used to determine the accuracy of the relative humidity readings. He referenced documentation dated 7/2/2012 (2012 confirmed-not a typo/misstatement) indicating as a result of discussion with the OR staff the alarm on the computerized tracking system, indicating temperature and humidity readings were outside defined parameters, was turned off.

On 10/18/2013 at approximately 5:15 p.m. an interview with the Registered Nurse (RN) Director of Surgical Services and the Registered Nurse (RN) Manager of the OR confirmed the alarm system for alerting staff to out of range temperature and humidity measurements had been turned off in July 2012. They stated they were well aware the temperature and humidity were not being maintained on an ongoing basis in accordance with facility policies based on AORN (Association of periOperative Registered Nurses) standards since prior to July 2012 through the present day. They indicated the surgeons wanted OR temperatures maintained below the minimum of 68 degrees Fahrenheit specified by policy. This resulted in the relative humidity rising above the maximum standard for relative humidity of 60 percent. They stated they brought their concerns regarding failing to maintain OR temperature and humidity within nationally recognized standards to the attention of numerous physicians, committees, and administration. The OR Manager cited particular concerns regarding patient safety. Both stated they were directed by Administration to comply with surgeons' requests with regard to the temperature of the ORs. They both stated in July 2012 they ceased monitoring the temperature and humidity in all four ORs as a result of being fully aware the temperature and humidity were out of compliance on an on-going basis, but having been directed by Administration not to implement a plan of correction. They saw no point in continuing to monitor a situation they were constrained from correcting. They indicated they had not taken any further action since turning off the alarms in July 2012.

A review of the facility policy titled "Temperature and Humidity Air Exchange Monitoring", Effective 08/1994, Reviewed 11/2011, Revised 01/2013-[Reference: AORN (Association of periOperative Registered Nurses) Standards Practice Guidelines, Safe Environment of Care]. states: "The standard temperature for the operating rooms should be maintained at 68-73 degrees Fahrenheit. The standard relative humidity is 30-60 percent. Any changes to room temperature should be discussed between the surgeon and anesthesiologist who will be responsible for the patient's welfare while in the OR and may adjust the temperature as per their best medical judgement. Notify Infection Control if temperature and humidity are outside the acceptable ranges so patient may be monitored for infections".

On 10/22/2013 at approximately 10:30 a.m. an interview with the Director of Risk Management revealed there were no Environmental Meeting Minutes discussing the Operating Room Temperatures or Relative Humidity. The interview and review of the Patient Safety Committee Meeting Minutes (regarding infection control surveillance) with the Director of Risk Management revealed no discussion of the Operating Rooms Temperature and Humidity variances.

On 10/18/2013 at 5:00 p.m. the above findings were confirmed with the Director of Risk Management.

Based on record review, policy review and staff interview it was determined the Registered Nurse failed to supervise and evaluate patient care related to assessing/reassessing post-operative patients in compliance with facility policies for 3 (#5, #7, #8) of 3 post-operative patients of 9 sampled records.

Findings include:

1. The PACU (Post Anesthesia Care Unit) record for Patient #5 indicated the patient was transported to her hospital room at 11:27 a.m. following orthopedic surgery on 10/17/13. A detailed review of the record failed to reveal documentation of an assessment of the patient upon arrival to her room on the 2 North nursing unit.

2. The PACU record for Patient #7 indicated the patient was transported to her hospital room at 10:45 a.m. following orthopedic surgery on 10/16/13. The first documentation of a nursing assessment of Patient #7's surgical dressing was dated 10/16/13 at 5:00 p.m., approximately 6 hours following the patient's arrival on the 2 North nursing unit following surgery.

3. The PACU record for Patient #8 indicated the patient was transported to her hospital room at 1:43 p.m. following orthopedic surgery on 8/19/13. The first documentation of a nursing assessment of the surgical sites was dated 8/21/13 at 8:00 a.m., approximately 42 hours following the patient's arrival on the 2 North nursing unit following surgery. The first vital signs were documented on 8/19/13 at 5:18 p.m., approximately 3 hours following the patient's arrival on the unit.

The policy "Reassessment of Patient with Physician Notification of Changes" , (no policy number) was reviewed on 10/18/13. Standard of Practice 2.4 indicated reassessment will occur before, during, and following surgical or invasive procedures. 2.5 included: patients status will be reassessed and documented upon arrival to the unit. 4.1 included: All changes inpatient assessment/reassessment will be documented in the medical record.

The policy "Assessment & Reassessment of Patients" , (no policy number) was reviewed on 10/18/13. Assessment Reassessment of Patients General Guidelines included: All assessments and reassessments are documented in the patient's medical record.

An interview was conducted with the RN Director of 2 North nursing unit on 10/18/13 at approximately 12:28 p.m. In response to questions regarding the nursing assessment of a patient returning from surgery, she indicated the RN would be expected to assess the general appearance of the patient, the vital signs, the status of the surgical site and/or dressing, and the patient's pain. She indicated the initial assessment of the patient upon arrival to the nursing unit following surgery would be documented in the record.

An interview was conducted with the Director of Risk Management on 10/18/13 at approximately 3:00 p.m. She confirmed the finding that 3 of 3 post-operative patients were not reassessed following surgery upon arrival to the nursing unit in compliance with facility policy.

Based on record review and staff interview it was determined the nursing staff failed to develop, implement and update individualized plans of care for each patient and implement care in accordance with the physician plan of care for 2 (#1, #8) of 9 sampled patients.

Findings include:

1. Patient #1 was transported to her hospital room at 2:20 p.m. following orthopedic surgery on 08/14/2013. The patient was on a Continuous Passive Motion (CPM) machine.

A review of the patients care plan revealed the patient was assessed for mobility impairment. A detailed review of the patient's record did not reveal any documentation of the patient being repositioned every two hours.

Review of the nurses' notes dated 08/18/2013 revealed the patient had a stage 2 pressure sore. A detailed review did not reveal notification to the patient's physician or surgeon by the nursing staff of the development of a pressure sore.

A review of the facility policy titled: "Skin Care Protocol-Interventional" #GN94016 States: "6.9 Turn patient every 2 hours and document in the clinical record".

An interview was conducted with the RN Director of 2 North and Patient Safety RN on 10/18/13 at approximately 2:30 p.m. The findings were confirmed.

2. Patient #8's physician orders dated 8/23/13 included to obtain a consultation with the wound care clinician for the prevention of decubitus ulcers.

Review of the medical record failed to reveal evidence of a consultation by the wound care clinician prior to discharge on 8/24/13 at 7:30 p.m.

An interview was conducted with the RN Director of 2 North on 10/18/13 at approximately 12:28 p.m. She confirmed Patient #8 did not receive the wound care consultation in accordance with the physician plan of care.

Based on observation, document review and interviews it was determined the facility failed to provide surgical services in accordance with their own policy and national recognized standards of practice in 4 of 4 Operating Rooms for monitoring of temperate and humidity.

On 10/18/2013 at 9:10 a.m. a tour of the Surgical Suite was conducted that revealed 4 Operating Rooms (OR). A request of the Temperature and Humidity Log book revealed the log was not being maintained.

A review of the facility policy titled "Temperature and Humidity Air Exchange Monitoring", Effective 08/1994, Reviewed 11/2011, Revised 01/2013-[Reference: ACORN (Association of periOperative Registered Nurses) Standards Practice Guidelines, Safe Environment of Care]. states: "Temperature and humidity levels in each operating room will be monitored and recorded each day...Log sheets are to be kept in the Temperature/Humidity Log Book in the OR."

Interview with the biomedical engineer on 10/18/13 at 5:00 p.m. revealed there was a computerized system for recording Operating Room temperature and relative humidity readings. He stated he discovered at the time of the request to run the report that Operating Room #2 was not reporting data and had not been collecting data since July 03, 2013. He also stated in July 2012 he was requested to shut off the alert system for the ORs notifying the Operating Room staff when the temperature and relative humidity readings were out acceptable range. He stated the temperature devices are calibrated once annually, but he does not know of any calibration methods used to determine the accuracy of the relative humidity readings.

The report was reviewed for April 1st to October 18, 2013. It revealed Operating Room #2 was not reporting and had not reported since July 02, 2013. The computerized temperature and humidity readings for operating rooms #1, #3 and #4 revealed out of range temperatures below the minimum standard of 68 degrees Fahrenheit and out of range relative humidity readings above the maximum standard of 60 percent.

On 10/18/2013 at approximately 5:15 p.m. an interview with the Registered Nurse (RN) Director of Surgical Services and the Registered Nurse (RN) Manager of the OR confirmed the alarm system for alerting staff to out of range temperature and humidity measurements had been turned off in July 2012. They stated they were aware the temperature and humidity were not being maintained on an ongoing basis in accordance with facility policies based on AORN (Association of periOperative Registered Nurses) standards since July 2012 through the present day. They indicated the surgeons wanted OR temperatures maintained below the minimum of 68 degrees Fahrenheit specified by policy. This resulted in the relative humidity rising above the maximum standard for relative humidity of 60 percent. They stated they brought their concerns regarding failing to maintain OR temperature and humidity within nationally recognized standards to the attention of numerous physicians, committees, and administration. Both stated they were directed by Administration to comply with surgeons' requests with regard to the temperature of the ORs. They both stated in July 2012 they ceased monitoring the temperature and humidity in all four ORs and were directed by Administration not to implement a plan of correction.

The failure to maintain nationally recognized standard and their own policy related to temperature and humidity in the ORs may be conducive to bacterial growth, which could lead to infections and compromise patient safety.

Based on the cumulative effect of the surgical staff failing to maintain the operating rooms' temperature and humidity within the national recognized standard it was determined the facility was not in compliance with the Condition of Participation Surgical Services.

Based on document review, observation and interviews it was determined the facility failed to follow their policy and acceptable standards of practice for monitoring and recording the temperature and humidity in 4 of 4 Operating Rooms (OR).

Findings include:

On 10/18/2013 at 9:10 a.m. a tour of the Surgical Suite was conducted revealing 4 Operating Rooms and 1 procedure room. A request of the Temperature and Humidity Log book revealed the log was not being maintained.

A review of the facility policy titled "Temperature and Humidity Air Exchange Monitoring", Effective 08/1994, Reviewed 11/2011, Revised 01/2013-[Reference: AORN (Association of periOperative Registered Nurses) Standards Practice Guidelines, Safe Environment of Care]. states: "Temperature and humidity levels in each operating room will be monitored and recorded each day shift normally staffed (i.e., Monday - Friday, excluding holidays). Each log sheet is to be used for one month. Log sheets are to be kept in the Temperature/Humidity Log Book in the OR".

A review of the computerized temperature and humidity log for April 1st to October 18, 2013 revealed Operating Room #2 was not reporting and had not reported since July 02, 2013. The computerized temperature and humidity readings for operating rooms #1, #3 and # 4 revealed out of range temperatures below the minimum standard of 68 degrees Fahrenheit and out of range relative humidity readings above the maximum standard of 60 percent established by facility policy titled "Temperature and Humidity Air Exchange Monitoring", Effective 08/1994, Reviewed 11/2011, Revised 01/2013-[Reference: AORN (Association of periOperative Registered Nurses) Standards Practice Guidelines, Safe Environment of Care].

On 10/18/2013 at approximately 5:15 p.m. an interview was conducted with the Registered Nurse (RN) Director of Surgical Services and the Registered Nurse (RN) Manager of OR. In response to questions, both confirmed the alarm system for alerting staff to out of range temperature and humidity measurements had been turned off in July 2012. They indicated they were well aware the temperature and humidity were not being maintained on an ongoing basis in accordance with facility policies based on AORN (Association of periOperative Registered Nurses) standards since prior to July 2012 through the present day. They indicated the surgeons wanted OR temperatures maintained below the minimum of 68 degrees Fahrenheit specified by policy. This resulted in the relative humidity rising above the maximum standard for relative humidity of 60 percent. They indicated they brought their concerns regarding failing to maintain OR temperature and humidity within nationally recognized ranges to the attention of numerous physicians, committees, and administration. The OR Manager cited particular concerns regarding patient safety. Both indicated they were directed by Administration to comply with surgeons' requests with regard to the temperature of the ORs. They both indicated in July 2012 they ceased monitoring the temperature and humidity in all four ORs as a result of being fully knowledgeable the temperature and humidity were out of compliance on an on-going basis, but having been directed by Administration not to implement a plan of correction. They saw no point in continuing to monitor a situation they were constrained from correcting. They indicated they had not taken any further action since turning off the alarms in July 2012.

On 10/18/2013 at 5:00 p.m. the above findings were confirmed with the Director of Risk Management.