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Based on interview and record review, the hospital failed to maintain a safe, sanitary and clean environment in the operating room (OR) when 2 of 10 OR rooms (OR 1 and 10) had misting (small water droplets resembling fog) of non-sterile water occur during surgical procedures for four of twelve sampled patients (1, 2, 3, and 4). This could potentially contaminate the surgical field. Findings:

1. On 7/28/14 the California Department of Public Health received a faxed report from the hospital's risk coordinator which indicated a misting event had occurred in OR 10.

The report indicated on 7/21/14 at 11:25 a.m. when Patient 1 was undergoing back surgery, misting occurred in OR 10 for four minutes.

Patient 1 was admitted to the hospital on 7/21/14 for medical treatment including surgery to the lower back.

Patient 1's record was reviewed on 1/26/15. The 7/21/14 operative note indicated there was misting during Patient 1's surgery.

2. On 9/15/14 the California Department of Public Health received a faxed report from the hospital's risk coordinator which indicated a misting event had occurred in OR 10.

The report indicated on 7/9/14 when Patient 2 was undergoing neck surgery, misting occurred in OR 10 for one to two minutes.

Patient 2 was admitted on 7/9/14 for medical treatment including surgery to the neck.

3. On 1/5/15, the California Department of Public Health received a faxed report from the hospital's risk coordinator which indicated a misting event had occurred in OR 1.

The report indicated on 1/2/15 at 9:30 p.m. when Patient 3 was undergoing a laparoscopic surgery (a procedure in which a lighted scope is used to perform the surgery), misting occurred in OR 1 for less than 5 seconds.

Patient 3 was admitted to the hospital on 1/2/15 for an outpatient surgical procedure.

During interviews on 1/26/15 at 2:10 p.m. circulating nurse A (CN A), circulating nurse B (CN B) and surgical technician A (ST A) confirmed the occurrence of the misting event on 1/2/15 in OR 1.

During the interview on the same date and time, ST A stated while surgery was in progress, a misting event occurred. ST A stated she felt the mist on her arms and could see water droplets on the surgical drapes, instrument stand and on Patient 3's lower legs. ST A described the mist as very fine, lasting less than 5 seconds and it did not come in contact with Patient 3's surgical site.

During an interview on 1/27/15 at 10:15 a.m., surgeon A (S A) confirmed on 1/2/15, during the laparoscopic procedure, a misting event occurred. S A stated the event lasted a few seconds and did not come in contact with Patient 3's surgical site.

During an interview on 1/28/15 at 8:30 a.m., anesthesiologist A (A A) confirmed the misting event on 1/2/15 during the laparoscopic procedure.

4. On 1/8/15, the California Department of Public Health received a faxed report from the hospital's risk coordinator which indicated a misting event had occurred in OR 1.

The report indicated on 1/6/15 at 10:15 a.m. when Patient 4 was undergoing surgery a misting occurred in OR 1 for less than 25 seconds.

Patient 4 was admitted to the hospital on 1/6/15 for a surgical procedure.

Record review of Patient 4's discharge summary dated 1/7/15 indicated Patient 4 had surgery on 1/6/15. The summary indicated, "The surgery was remarkable for high humidity in the OR, with brief period of visible misting".

During an interview on 1/27/15 at 9 a.m., surgical technician B (ST B) stated she was present for the surgery. She stated about an hour into the surgery, the OR temperature felt warm and a staff member turned down the thermostat on the OR wall. ST B stated immediately after the thermostat was adjusted mist which resembled ocean or beach fog was visible for about 20 seconds and then cleared. ST B stated staff immediately covered any exposed area of Patient 4.

During an interview on 1/27/15 at 9:40 a.m., surgeon B (S B) stated when she performed Patient 4's surgery the room became warm and she asked a circulating nurse to turn down the room temperature. After the temperature was turned down, misting was noted first near the light fixtures over the operating table which cleared in less than 30 seconds.

During an interview on 1/26/15 at 11:14 a.m. the Infection Control Officer (ICO) confirmed the misting events for Patients 1, 2, 3, and 4. the ICO stated Patients 1, 2, 3, and 4 were added to her list entitled "Misted Patients in OR " for their 6-month follow-up of these patients.

During an interview on 1/27/15 at 2:30 p.m. the chief facilities engineer (CFE) confirmed misting occurred in the OR for Patients 1, 2, 3, and 4.