HospitalInspections.org

Based on observation, staff interviews, and review of facility policies, manufacturer recommendation for a glucometer, and review of the 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 ensure their infection control system developed to identify, investigate, and control infections and communicable diseases were followed to protect all patients. The OR staff failed to obtain temperatures and humidity levels in OR suite #1 for July 2012 until present date. The facility failed to monitor temperature and humidity levels in three (3) of four (4) OR suites (#1, #2 and #3) with humidity level readings above the acceptable range of 30-60 for multiple days in July 2012. The OR staff failed to notify the maintenance department; therefore, no adjustments were made to correct the problem.

In addition, observation during a blood glucose check revealed the facility staff used an alcohol wipe to clean the glucometer instead of the recommended disinfectant wipe.

The findings include:

1. Review of facility policy...preparing the OR environment, revised 10/08/2011, revealed the OR staff are to monitor the OR's temperature and humidity levels. A room temperature between 68-73 degrees Fahrenheit (F) inhibits bacterial growth. A relative humidity of 30-60% facilitates decreased bacterial growth and static electricity.

Review of the 2012 edition of the Association of Operating Room Nurses (AORN) revealed established recommended practices to reflect the acceptable relative humidity (RH) ranges of 30-60% and temperature range of 68-73 degrees F. The 2012 edition of AORN revealed high humidity levels increase the risk for microbial growth in areas where surgery or procedures are performed. The facility stated they used the AORN guidelines.

Observation of OR suite #1 on 08/07/12 at 11:50 AM, revealed no mechanism to read temperature or humidity level. Upon investigation, it was found the thermostat had been broken since June 2012.

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.

Interview with the Director of Surgical Services, on 08/08/12 at 10:00 AM, revealed the thermostat in OR #1 has been broken for the entire month of July and he was only informed of this today. An environmental aide is supposed to obtain temperatures and humidity levels in each OR suite (OR #1, 2, 3, & 4) and record those readings on the room humidity and temperature log. He stated he had not reviewed nor analyzed those logs to ensure the temperatures and humidity levels were within the AORN acceptable range. He stated he had not notified the maintenance department of any concerns and since he had not identified a problem, had not presented the findings to the safety committee.


Interview with the Director of Maintenance, on 08/08/12 at 10:05 AM, 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, & 3 are older OR suites and are not connected to the computer system. Therefore, the OR staff must take temperature and humidity readings manually from the thermostat on the wall. He was not aware the thermostat was broken in OR #1. He further stated he had not been notified of any problems with humidity levels in OR #1, 2, or #3. He indicated he could have checked the air handler system and chillers to ensure they were working properly and make adjustments to correct the problem.


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

2. Review of the manufacturer recommendation for cleaning of the Precision Xceed Pro blood glucose meter revealed the manufacturer recommends cleaning the meter with Sani-cloth or Clorox Germicidal wipes. The booklet stated alcohol should never be used.

Observation, on 08/08/12 at 8:35 AM, revealed RN #5 went into Room #221 to obtain a blood glucose reading. The nurse scanned the patient's ID bracelet and her badge. The nurse donned clean gloves, used a lancet to stick the patient's right middle finger and obtained a blood drop which was placed on a test strip. Blood sugar reading was obtained. The nurse placed the glucose meter back into the case without wiping the meter. The nurse took the meter case back to the nurses' station.

Interview with the nurse, on 08/08/12 at 8:40 AM, revealed she would clean the meter with alcohol wipes. She acknowledged she had not cleaned the meter prior to placing it back into the case. She then took the glucose meter from the case and wiped it with an alcohol wipe. A Sani wipe container was sitting on the counter where the nurse had placed the meter.

At 11:20 AM, RN #2 performed a blood glucose check for Patient # 14 in Room # 205.
The nurse removed the meter from the case, washed her hands, and donned clean gloves.
The nurse put in her ID code and scan the patient's ID bracelet. A fingerstick to the patient's left ring finger was performed. The nurse removed her gloves and placed the meter back into the case without cleaning.

At 11:35 AM, the same nurse obtained a blood glucose reading from Patient# 15 in Room # 201. The nurse wiped the meter off prior to use with an alcohol wipe. Interview with the nurse at the time of the observation reveled she always cleans the meter with alcohol wipes.

Interview with the Infection Preventionist, on 08/08/12 at 12:30 PM, revealed alcohol wipes are not suppose to be used to clean the glucose meters. She stated nurses are trained to use Sani-wipes disinfectant. She also stated the manufacturer recommended using Sani-wipes.