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Humidity levels in the operating room (OR) were not maintained within acceptable rages according to NFPA 99 5.4.1.1 (equal to or greater than 35 percent (%) and the Association of periOperative Registered Nurses Perioperative Standards and Recommended Practices, 2010 edition, p. 221 (relative humidity should be maintained between 30% and 60%).

Based on observation, record review, and interview, humidity levels for the OR were not maintained within acceptable parameters. Findings include:

1. Observation at 9:20 a.m. on 12/20/11 revealed a temperature gauge and relative humidity gauge were on the wall in the OR. Interview with the OR manager at the time of the observation revealed the temperature and humidity level in the OR was taken and written on the patient's chart before surgery. Testing of the device at that time by the OR manager revealed the OR humidity level was 17%.

Review of four of four surgical procedure charts revealed the humidity levels were found at 25%, no recorded level, 21%, and 20.5%.

Review of the quality assurance audit conducted from 2/4/11 through 4/1/11 revealed fifteen surgical records had relative humidity recorded from 22-64%.

Review of the computer generated relative humidity recordings from 12/20/11 through 12/21/11 revealed the lowest percentage was 16.343% and the highest percentage was 35.342003 %. Interview with the environmental services supervisor at the time of the record review revealed the system automatically checked and recorded the relative humidity every 10 minutes of every day. He stated he was not aware what the acceptable relative humidity levels should be for the operating room. He also stated he was not aware if the computer generated program could be set up with an alarm. Nor was he unsure if that alarm would alert the maintenance personnel and OR manager if the relative humidity level was out of the accepted range during surgical procedures.

No policy or procedure could be located or provided that included proper and acceptable guidelines for temperature and humidity in the OR.

A. Based on observation and interview, the provider failed to maintain corridor separation from use areas by ceilings with at least a 30 minute fire resistance rating. The housekeeping closet and electrical room by the board room had no ceiling to maintain a smoke barrier. (Refer to LSC 2000 Section 8.4.1.2 Special Hazard Protection.) Findings include:

1. Observation at 10:45 a.m. on 12/20/11 revealed the ceiling in the housekeeping closet and adjoining electrical room by the board room did not exist. The rafters were visible in both ceilings. The automatic sprinkler heads and smoke detection system was located in the attic space of those visible rafters. Interview with the environmental services supervisor (ESS) at the time of the observation confirmed that finding. He stated he was not aware those ceilings had not been finished with gypsum board, tape, and texture like the walls of the room.

B. Based on observation and interview the provider failed to install permanent wiring in the doctor's lounge and a doctor's office in the clinic. Power strips were found in-use for microwaves, refrigerators, toasters, shredders, and fans. Findings include:

1. Observation from 10:45 a.m. to 11:15 a.m. on 12/20/11 revealed power strips in-use for microwaves, refrigerators, toasters, shredder, and fans in the doctor's lounge and a doctor's office in the clinic. Interview with the environmental services supervisor at the time of the observation confirmed that finding. He stated he tried to monitor use of the power strips but staff would bring them in without his approval.

Based on observation and interview, the provider failed to install permanent wiring in the procedure room of the operating room (OR) suite. Three power strips were found in-use for medical equipment in that room. Findings include:

1. Observation at 9:45 a.m. on 12/20/11 revealed three power strips in-use for endoscopy equipment in the procedure room of the OR suite. Interview with the OR manager at the time of the observation confirmed those findings. She stated the power strips were needed for all the monitoring equipment used during endoscopic procedures. She stated she was not aware power strips could not be used for medical equipment.