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150 PIONEER LANE

BISHOP, CA 93514

No Description Available

Tag No.: K0047

Based on observation, the facility failed to maintain exit lights, as evidenced by one exit light that failed to illuminate. This could cause delayed evacuation from the building in the event of a fire. This affected one of two off site modular locations.


Findings:

On 3/20/13, during a tour of the Outpatient Services area, with the Director of Pant Operations, the exit signs were observed.

At 2:23 p.m., the exit light failed to illuminate at the back door of the infusion area. The light was tested by depressing the test button.

No Description Available

Tag No.: K0050

Based on document review, the facility failed to provide documentation for 3 of 4 fire drills, on 1 of 3 shifts, and failed to activate the fire alarm during fire drills. This could result in a delayed staff response, in the event of a fire and affected three of three smoke compartments on two of two floors.

Findings:

On 3/20/2013 at 9:41 a.m., the facility Fire Drill Reports were reviewed.
1. There was no documentation of fire drills for the p.m. shift during the second, third and fourth quarters of 2012.
2. There was no fire alarms activated for the fire drill on the p.m. shift in the first quarter 2012.
There were no alarms activated during fire drills on the a.m. shift in July, August, September and December 2012. Alarms were not activated for three of four quarters.

No Description Available

Tag No.: K0054

Based on observation, the facility failed to maintain the smoke detectors in 1 of 3 smoke compartments on the first floor. This was evidenced by one smoke detector that failed to activate when tested. This could result in a delay in notification in the event of a fire.


Findings:

On 3/20/2013, at 2:51 p.m., the fire alarm system was tested. The smoke detector failed to activate when tested with canned smoke and a magnet, in the emergency room reception area. The smoke detector was tested 4-5 times.

No Description Available

Tag No.: K0064

Based on observation, the facility failed to maintain all fire extinguishers. This was evidenced by no monthly inspections on one fire extinguisher. This affected 1 of 3 smoke compartments on the first floor, and could result in the failure of the fire extinguisher in the event of a fire.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition
4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.
4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

Findings:

On 3/20/13, during a tour of the facility, with the Director of Plant Operations, the fire extinguishers were observed.
At 10:49 a.m., there were no monthly inspections for 2/2013, for the fire extinguisher in the standby kitchen.

No Description Available

Tag No.: K0076

Based on document review and interview, the facility failed to maintain the humidity levels in 3 of 3 operating rooms at 35 percent or greater. This could result in an increased risk of fire. This affects 1 of 3 smoke compartments on the 1st floor.

Findings:

From 3/18/13 through 3/21/2013, the NIH (Northern Inyo Hospital) OR (Operating Room) Temperature and Humidity Report logs were reviewed. The humidity levels are monitored hourly through the HVAC system. The humidity levels in 3 of 3 operating rooms read at levels below 35 percent starting in January 2013 through 3/18/13.

On 3/20/2013, at 2:30 p.m., during an interview with plant operations staff, staff was asked what the facility was doing to correct the humidity in the three operating rooms. The Director of Plant Operations stated they were working with the vendor, over the phone, to correct the problem. He stated he knows there is a problem and they are trying to adjust the system to correct the problem.

He reported operating room staff monitor the humidity and log it, in each OR. The logs from the ORs were requested.

The humidity logs from the operating rooms were received at 3:35 p.m., and reviewed. The logs indicated the days the humidity was out of range.
For January 2013, in operating room 1, the humidity was out of range 19 of 19 days recorded. In February 2013, in operating room 2, the humidity level was out of range 16 of 16 days recorded. In March 2013, in operating room 3, the humidity level was out of range for 17 of 17 days recorded.

During an interview, the OR Manager was asked if they cancel or delay surgeries when the humidity levels are low. She stated not usually. The hand written logs have a column to indicate if they notify maintenance if the humidity is out of range. The column was not filled out on any OR report. The OR manager stated they do notify the maintenance department.

The humidity levels recorded from the HVAC computer were as follows:
OR 1 - January
On 1/5/13 the humidity ranged from 16.67 to 36.27 percent.
On 1/7/2013 the humidity ranged from 17.28 to 39.26 percent.
On 1/8/2013 the humidity ranged from 23.78 to 26.47 percent.
On 1/9/2013 the humidity ranged from 21.74 to 26.32 percent.
On 1/10/2013 the humidity ranged from 16.09 to 35.44 percent.
On 1/11/2013 the humidity ranged from 14.78 to 34.98 percent.
On 1/12/2013 the humidity ranged from 29.37 to 34.43 percent.
On 1/13/2013 the humidity ranged from 23.17 to 32.05 percent.
On 1/14/2013 the humidity ranged from 17.34 to 35.78 percent.
On 1/15/2013 the humidity ranged between 16.18 to 38.80 percent.
On 1/16/2013 the humidity ranged between 15.18 to 37.30 percent.
On 1/17/2013 the humidity ranged between 15.76 to 35.47 percent.
On 1/18/2013 the humidity ranged between 19.51 to 36.72 percent.
On 1/19/2013 the humidity ranged between 17.41 to 36.02 percent.
On 1/20/2013 the humidity ranged between 15.54 to 35.59 percent.
On 1/21/2013 the humidity ranged between 17.65 to 36.51 percent.
On 1/22/2013 the humidity ranged between 15.03 to 38.98 percent.
On 1/23/2013 the humidity ranged between 17.28 to 38.92 percent.
On 1/27/2013 the humidity ranged between 22.50 to 35.69 percent.
On 1/28/2013 the humidity ranged between 16.31 to 37.12 percent.
On 1/29/2013 the humidity ranged between 17.99 to 35.87 percent.
On 1/30/2013 the humidity ranged between 21.31 to 27.69 percent.
On 1/31/2013 the humidity ranged between 19.63 to 39.41 percent.
February -
On 2/1/2013 the humidity ranged between 17.95 to 37.55 percent.
On 2/2/2013 the humidity ranged from 17.31 to 38.13 percent.
On 2/3/2013 the humidity ranged from 18.81 to 31.87 percent.
On 2/4/2013 the humidity ranged from 15.82 to 38.13 percent.
On 2/5/2013 the humidity ranged from 18.05 to 38.00 percent.
On 2/6/2013 the humidity ranged from 11.70 to 35.56 percent.
On 2/7/2013 the humidity ranged from 11.61 to 35.38 percent.
On 2/8/2013 the humidity ranged from 17.80 to 37.94 percent.
On 2/9/2013 the humidity ranged from 16.09 to 37.70 percent.
On 2/10/2013 the humidity ranged from 13.13 to 37.33 percent.
On 2/11/2013 the humidity ranged from 26.01 to 39.81 percent.
On 2/12/2013 the humidity ranged from 11.70 to 38.83 percent.
On 2/13/2013 the humidity ranged from 14.54 to 37.79 percent.
On 2/14/2013 the humidity ranged from 18.84 to 24.24 percent.
On 2/15/2013 the humidity ranged from 13.35 to 38.86 percent.
On 2/16/2013 the humidity ranged from 11.61 to 37.58 percent.
On 2/17/2013 the humidity ranged from 17.19 to 37.00 percent.
On 2/18/2013 the humidity ranged from 16.46 to 36.85 percent.
On 2/19/2013 the humidity ranged from 11.64 to 36.63 percent.
On 2/20/2013 the humidity ranged from 17.01 to 37.94 percent.
On 2/21/2013 the humidity ranged from 18.23 to 36.63 percent.
On 2/22/2013 the humidity ranged from 12.64 to 35.41 percent.
On 2/23/2013 the humidity ranged from 12.34 to 18.72 percent.
On 2/24/2013 the humidity ranged from 11.58 to 35.20 percent.
On 2/25/2013 the humidity ranged from 11.49 to 33.34 percent.
On 2/26/2013 the humidity ranged from 11.58 to 31.87 percent.
On 2/27/2013 the humidity ranged from 11.55 to 34.10 percent.
On 2/28/2013 the humidity ranged from 11.55 to 33.00 percent.
On 3/1/2013 the humidity ranged from 12.13 to 24.12 percent.
On 3/2/2013 the humidity ranged from 17.86 to 18.50 percent.
On 3/3/2013 the humidity ranged from 18.38 to 31.32 percent.
On 3/4/2013 the humidity ranged from 11.58 to 28.94 percent.
On 3/5/2013 the humidity ranged from 16.40 to 23.69 percent.
On 3/6/2013 the humidity ranged from 11.67 to 22.38 percent.
On 3/7/2013 the humidity ranged from 12.98 to 26.59 percent.
On 3/8/2013 the humidity ranged from 18.69 to 27.57 percent.
On 3/9/2013 the humidity ranged from 11.67 to 20.88 percent.
On 3/10/2013 the humidity ranged from 11.52 to 31.63 percent.
On 3/11/2013 the humidity ranged from 11.58 to 30.07 percent.
On 3/12/2013 the humidity ranged from 11.64 to 15.70 percent.
On 3/13/2013 the humidity ranged from 12.52 to 16.31 percent.
On 3/14/2013 the humidity ranged from 15.39 to 20.15 percent.
On 3/15/2013 the humidity ranged from 11.58 to 30.99 percent.
On 3/16/2013 the humidity ranged from 11.58 to 29.37 percent.
On 3/17/2013 the humidity ranged from 11.58 to 29.37 percent.
On 3/18/2013 the humidity ranged from 11.61 to 24.46 percent.

OR 2 - January
On 1/1/2013 the humidity ranged from 27.87 to 29.92 percent.
On 1/2/2013 the humidity ranged from 27.97 to 30.47 percent.
On 1/3/2013 the humidity ranged from 28.00 to 30.26 percent.
On 1/4/2013 the humidity ranged from 28.52 to 30.10 percent.
On 1/5/2013 the humidity ranged from 25.04 to 26.35 percent.
On 1/6/2013 the humidity ranged from 23.82 to 25.86 percent.
On 1/7/2013 the humidity ranged from 23.39 to 25.28 percent.
On 1/8/2013 the humidity ranged from 23.91 to 27.20 percent.
On 1/9/2013 the humidity ranged from 26.50 to 28.24 percent.
On 1/10/2013 the humidity ranged from 24.52 to 27.48 percent.
On 1/11/2013 the humidity ranged from 25.01 to 26.75 percent.
On 1/12/2013 the humidity ranged from 25.53 to 27.05 percent.
On 1/13/2013 the humidity ranged from 21.65 to 26.56 percent.
On 1/14/2013 the humidity ranged from 18.02 to 24.37 percent.
On 1/15/2013 the humidity ranged from 22.17 to 24.43 percent.
On 1/16/2013 the humidity ranged from 21.71 to 25.49 percent.
On 1/17/2013 the humidity ranged from 24.61 to 27.08 percent.
On 1/18/2013 the humidity ranged from 26.10 to 28.24 percent.
On 1/19/2013 the humidity ranged from 27.17 to 28.42 percent.
On 1/20/2013 the humidity ranged from 27.63 to 28.88 percent.
On 1/21/2013 the humidity ranged from 26.47 to 28.30 percent.
On 1/22/2013 the humidity ranged from 25.49 to 27.75 percent.
On 1/23/2013 the humidity ranged from 24.64 to 26.47 percent.
On 1/27/2013 the humidity ranged from 28.58 to 36.69 percent.
On 1/28/2013 the humidity ranged from 28.03 to 30.44 percent.
On 1/29/2013 the humidity ranged from 26.38 to 28.12 percent.
On 1/30/2013 the humidity ranged from 25.53 to 27.81 percent.
On 1/31/2013 the humidity ranged from 24.18 to 25.77 percent.
February -
On 2/1/2013 the humidity ranged from 24.76 to 26.29 percent.
On 2/2/2013 the humidity ranged from 24.52 to 26.04 percent.
On 2/3/2013 the humidity ranged from 23.57 to 25.07 percent.
On 2/4/2013 the humidity ranged from 23.33 to 26.20 percent.
On 2/5/2013 the humidity ranged from 24.82 to 26.59 percent.
On 2/6/2013 the humidity ranged from 23.14 to 28.15 percent.
On 2/7/2013 the humidity ranged from 18.78 to 26.01 percent.
On 2/8/2013 the humidity ranged from 23.08 to 26.26 percent.
On 2/9/2013 the humidity ranged from 23.24 to 26.68 percent.
On 2/10/2013 the humidity ranged from 22.60 to 26.14 percent.
On 2/11/2013 the humidity ranged from 22.23 to 26.47 percent.
On 2/12/2013 the humidity ranged from 23.85 to 28.09 percent.
On 2/13/2013 the humidity ranged from 23.51 to 26.78 percent.
On 2/14/2013 the humidity ranged from 22.41 to 23.57 percent.
On 2/15/2013 the humidity ranged from 21.89 to 24.95 percent.
On 2/16/2013 the humidity ranged from 24.15 to 26.65 percent.
On 2/17/2013 the humidity ranged from 26.01 to 27.33 percent.
On 2/18/2013 the humidity ranged from 25.04 to 27.39 percent.
On 2/19/2013 the humidity ranged from 24.21 to 27.23 percent.
On 2/20/2013 the humidity ranged from 24.18 to 26.78 percent.
On 2/21/2013 the humidity ranged from 26.26 to 27.75 percent.
On 2/22/2013 the humidity ranged from 18.51 to 28.18 percent.
On 2/23/2013 the humidity ranged from 16.16 to 17.93 percent.
On 2/24/2013 the humidity ranged from 15.00 to 16.74 percent.
On 2/25/2013 the humidity ranged from 15.85 to 17.56 percent.
On 2/26/2013 the humidity ranged from 14.54 to 18.11 percent.
On 2/27/2013 the humidity ranged from 16.28 to 17.65 percent.
On 2/28/2013 the humidity ranged from 15.85 to 17.16 percent.
March -
On 3/1/2013 the humidity ranged from 16.52 to 19.82 percent.
On 3/2/2013 the humidity ranged from 19.06 to 19.67 percent.
On 3/3/2013 the humidity ranged from 19.51 to 26.10 percent.
On 3/4/2013 the humidity ranged from 19.97 to 26.87 percent.
On 3/5/2013 the humidity ranged from 20.12 to 21.74 percent.
On 3/6/2013 the humidity ranged from 16.67 to 20.89 percent.
On 3/7/2013 the humidity ranged from 16.34 to 22.87 percent.
On 3/8/2013 the humidity ranged from 23.45 to 27.72 percent.
On 3/9/2013 the humidity ranged from 17.53 to 24.33 percent.
On 3/10/2013 the humidity ranged from 16.77 to 18.99 percent.
On 3/11/2013 the humidity ranged from 14.81 to 17.01 percent.
On 3/12/2013 the humidity ranged from 14.29 to 15.91 percent.
On 3/13/2013 the humidity ranged from 14.75 to 16.13 percent.
On 3/14/2013 the humidity ranged from 16.13 to 19.54 percent.
On 3/15/2013 the humidity ranged from 17.71 to 19.70 percent.
On 3/16/ 2013 the humidity ranged from 17.80 to 19.73 percent.
On 3/17/2013 the humidity ranged from 16.64 to 19.02 percent.
On 3/18/2013 the humidity ranged from 15.48 to 18.23 percent.

OR 3 - January -
On 1/1/2013 the humidity ranged from 16.39 to 32.20 percent.
On 1/2/2013 the humidity ranged from 17.33 to 31.68 percent.
On 1/3/2013 the humidity ranged from 18.74 to 31.34 percent.
On 1/4/2013 the humidity ranged from 16.51 to 32.90 percent.
On 1/5/2013 the humidity ranged from 16.82 to 31.01 percent.
On 1/6/2013 the humidity ranged from 17.30 to 31.92 percent.
On 1/7/2013 the humidity ranged from 17.73 to 32.04 percent.
On 1/8/2013 the humidity ranged from 23.07 to 29.24 percent.
On 1/9/2013 the humidity ranged from 24.32 to 29.45 percent.
On 1/10/2013 the humidity ranged from 16.05 to 31.56 percent.
On 1/11/2013 the humidity ranged from 15.63 to 30.58 percent.
On 1/12/2013 the humidity ranged from 24.45 to 29.72 percent.
On 1/13/2013 the humidity ranged from 22.61 to 27.25 percent.
On 1/14/2013 the humidity ranged from 15.69 to 27.95 percent.
On 1/15/2013 the humidity ranged from 15.14 to 31.89 percent.
On 1/16/2013 the humidity ranged from 14.68 to 30.21 percent.
On 1/17/2013 the humidity ranged from 13.73 to 29.51 percent.
On 1/18/2013 the humidity ranged from 13.46 to 28.87 percent.
On 1/19/2013 the humidity ranged from 15.63 to 28.32 percent.
On 1/20/2013 the humidity ranged from 15/05 to 27.95 percent.
On 1/21/2013 the humidity ranged from 17.43 to 29.48 percent.
On 1/22/2013 the humidity ranged from 14.19 to 30.21 percent.
On 1/23/2013 the humidity ranged from 15.05 to 30.88 percent.
On 1/27/2013 the humidity ranged from 18.77 to 32.99 percent.
On 1/28/2013 the humidity ranged from 15.87 to 29.51 percent.
On 1/29/2013 the humidity ranged from 17.61 to 28.84 percent.
On 1/30/2013 the humidity ranged from 18.77 to 28.60 percent.
On 1/31/2013 the humidity ranged from 18.77 to 31.25 percent.
February -
On 2/1/2013 the humidity ranged from 17.09 to 32.50 percent.
On 2/2/2013 the humidity ranged from 17.76 to 32.50 percent.
On 2/3/2013 the humidity ranged from 18.98 to 32.99 percent.
On 2/4/2013 the humidity ranged from 16.51 to 33.66 percent.
On 2/5/2013 the humidity ranged from 16.42 to 32.44 percent.
On 2/6/2013 the humidity ranged from 10.99 to 29.45 percent.
On 2/7/2013 the humidity ranged from 11.02 to 27.92 percent.
On 2/8/2013 the humidity ranged from 19.50 to 29.88 percent.
On 2/9/2013 the humidity ranged from 15.38 to 31.95 percent.
On 2/10/2013 the humidity ranged from 11.69 to 31.28 percent.
On 2/11/2013 the humidity ranged from 21.52 to 29.66 percent.
On 2/12/2013 the humidity ranged from 11.17 to 34.03 percent.
On 2/13/2013 the humidity ranged from 13.95 to 30.18 percent.
On 2/14/2013 the humidity ranged from 17.61 to 22.89 percent.
On 2/15/2013 the humidity ranged from 16.11 to 30.27 percent.
On 2/16/2013 the humidity ranged from 11.17 to 28.69 percent.
On 2/17/2013 the humidity ranged from 15.72 to 30.12 percent.
On 2/18/2013 the humidity ranged from 15.23 to 29.42 percent.
On 2/19/2013 the humidity ranged from 10.99 to 28.17 percent.
On 2/20/2013 the humidity ranged from 16.24 to 29.97 percent.
On 2/21/2013 the humidity ranged from 16.85 to 28.66 percent.
On 2/22/2013 the humidity ranged from 11.17 to 27.01 percent.
On 2/23/2013 the humidity ranged from 11.02 to 15.47 percent.
On 2/24/2013 the humidity ranged from 11.02 to 25.42 percent.
On 2/25/2013 the humidity ranged from 10.96 to 23.01 percent.
On 2/26/2013 the humidity ranged from 11.02 to 25.51 percent.
On 2/27/2013 the humidity ranged from 10.96 to 26.31 percent.
On 2/28/2013 the humidity ranged from 10.99 to 24.11 percent.
On 3/1/2013 the humidity ranged from 16.54 to 22.68 percent.
On 3/2/2013 the humidity ranged from 16.79 to 19.47 percent.
On 3/3/2013 the humidity ranged from 17.73 to 30.95 percent.
On 3/4/2013 the humidity ranged from 11.05 to 27.92 percent.
On 3/5/2013 the humidity ranged from 16.05 to 23.65 percent.
On 3/6/2013 the humidity ranged from 12.67 to 22.19 percent.
On 3/7/2013 the humidity ranged from 13.92 to 27.01 percent.
On 3/8/2013 the humidity ranged from 20.17 to 28.38 percent.
On 3/9/2013 the humidity ranged from 13.18 to 21.85 percent.
On 3/10/2013 the humidity ranged from 12.73 to 22.68 percent.
On 3/11/2013 the humidity ranged from 12.09 to 24.78 percent.
On 3/12/2013 the humidity ranged from 10.99 to 16.88 percent.
On 3/13/2013 the humidity ranged from 12.51 to 16.69 percent.
On 3/14/2013 the humidity ranged from 16.02 to 42.30 percent.
On 3/15/2013 the humidity ranged from 13.25 to 23.99 percent.
On 3/16/2013 the humidity ranged from 10.99 to 24.29 percent.
On 3/17/2013 the humidity ranged from 11.11 to 23.04 percent.
On 3/18/2013 the humidity ranged from 11.14 to 25.54 percent.

LIFE SAFETY CODE STANDARD

Tag No.: K0047

Based on observation, the facility failed to maintain exit lights, as evidenced by one exit light that failed to illuminate. This could cause delayed evacuation from the building in the event of a fire. This affected one of two off site modular locations.


Findings:

On 3/20/13, during a tour of the Outpatient Services area, with the Director of Pant Operations, the exit signs were observed.

At 2:23 p.m., the exit light failed to illuminate at the back door of the infusion area. The light was tested by depressing the test button.

LIFE SAFETY CODE STANDARD

Tag No.: K0050

Based on document review, the facility failed to provide documentation for 3 of 4 fire drills, on 1 of 3 shifts, and failed to activate the fire alarm during fire drills. This could result in a delayed staff response, in the event of a fire and affected three of three smoke compartments on two of two floors.

Findings:

On 3/20/2013 at 9:41 a.m., the facility Fire Drill Reports were reviewed.
1. There was no documentation of fire drills for the p.m. shift during the second, third and fourth quarters of 2012.
2. There was no fire alarms activated for the fire drill on the p.m. shift in the first quarter 2012.
There were no alarms activated during fire drills on the a.m. shift in July, August, September and December 2012. Alarms were not activated for three of four quarters.

LIFE SAFETY CODE STANDARD

Tag No.: K0054

Based on observation, the facility failed to maintain the smoke detectors in 1 of 3 smoke compartments on the first floor. This was evidenced by one smoke detector that failed to activate when tested. This could result in a delay in notification in the event of a fire.


Findings:

On 3/20/2013, at 2:51 p.m., the fire alarm system was tested. The smoke detector failed to activate when tested with canned smoke and a magnet, in the emergency room reception area. The smoke detector was tested 4-5 times.

LIFE SAFETY CODE STANDARD

Tag No.: K0064

Based on observation, the facility failed to maintain all fire extinguishers. This was evidenced by no monthly inspections on one fire extinguisher. This affected 1 of 3 smoke compartments on the first floor, and could result in the failure of the fire extinguisher in the event of a fire.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition
4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.
4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

Findings:

On 3/20/13, during a tour of the facility, with the Director of Plant Operations, the fire extinguishers were observed.
At 10:49 a.m., there were no monthly inspections for 2/2013, for the fire extinguisher in the standby kitchen.

LIFE SAFETY CODE STANDARD

Tag No.: K0076

Based on document review and interview, the facility failed to maintain the humidity levels in 3 of 3 operating rooms at 35 percent or greater. This could result in an increased risk of fire. This affects 1 of 3 smoke compartments on the 1st floor.

Findings:

From 3/18/13 through 3/21/2013, the NIH (Northern Inyo Hospital) OR (Operating Room) Temperature and Humidity Report logs were reviewed. The humidity levels are monitored hourly through the HVAC system. The humidity levels in 3 of 3 operating rooms read at levels below 35 percent starting in January 2013 through 3/18/13.

On 3/20/2013, at 2:30 p.m., during an interview with plant operations staff, staff was asked what the facility was doing to correct the humidity in the three operating rooms. The Director of Plant Operations stated they were working with the vendor, over the phone, to correct the problem. He stated he knows there is a problem and they are trying to adjust the system to correct the problem.

He reported operating room staff monitor the humidity and log it, in each OR. The logs from the ORs were requested.

The humidity logs from the operating rooms were received at 3:35 p.m., and reviewed. The logs indicated the days the humidity was out of range.
For January 2013, in operating room 1, the humidity was out of range 19 of 19 days recorded. In February 2013, in operating room 2, the humidity level was out of range 16 of 16 days recorded. In March 2013, in operating room 3, the humidity level was out of range for 17 of 17 days recorded.

During an interview, the OR Manager was asked if they cancel or delay surgeries when the humidity levels are low. She stated not usually. The hand written logs have a column to indicate if they notify maintenance if the humidity is out of range. The column was not filled out on any OR report. The OR manager stated they do notify the maintenance department.

The humidity levels recorded from the HVAC computer were as follows:
OR 1 - January
On 1/5/13 the humidity ranged from 16.67 to 36.27 percent.
On 1/7/2013 the humidity ranged from 17.28 to 39.26 percent.
On 1/8/2013 the humidity ranged from 23.78 to 26.47 percent.
On 1/9/2013 the humidity ranged from 21.74 to 26.32 percent.
On 1/10/2013 the humidity ranged from 16.09 to 35.44 percent.
On 1/11/2013 the humidity ranged from 14.78 to 34.98 percent.
On 1/12/2013 the humidity ranged from 29.37 to 34.43 percent.
On 1/13/2013 the humidity ranged from 23.17 to 32.05 percent.
On 1/14/2013 the humidity ranged from 17.34 to 35.78 percent.
On 1/15/2013 the humidity ranged between 16.18 to 38.80 percent.
On 1/16/2013 the humidity ranged between 15.18 to 37.30 percent.
On 1/17/2013 the humidity ranged between 15.76 to 35.47 percent.
On 1/18/2013 the humidity ranged between 19.51 to 36.72 percent.
On 1/19/2013 the humidity ranged between 17.41 to 36.02 percent.
On 1/20/2013 the humidity ranged between 15.54 to 35.59 percent.
On 1/21/2013 the humidity ranged between 17.65 to 36.51 percent.
On 1/22/2013 the humidity ranged between 15.03 to 38.98 percent.
On 1/23/2013 the humidity ranged between 17.28 to 38.92 percent.
On 1/27/2013 the humidity ranged between 22.50 to 35.69 percent.
On 1/28/2013 the humidity ranged between 16.31 to 37.12 percent.
On 1/29/2013 the humidity ranged between 17.99 to 35.87 percent.
On 1/30/2013 the humidity ranged between 21.31 to 27.69 percent.
On 1/31/2013 the humidity ranged between 19.63 to 39.41 percent.
February -
On 2/1/2013 the humidity ranged between 17.95 to 37.55 percent.
On 2/2/2013 the humidity ranged from 17.31 to 38.13 percent.
On 2/3/2013 the humidity ranged from 18.81 to 31.87 percent.
On 2/4/2013 the humidity ranged from 15.82 to 38.13 percent.
On 2/5/2013 the humidity ranged from 18.05 to 38.00 percent.
On 2/6/2013 the humidity ranged from 11.70 to 35.56 percent.
On 2/7/2013 the humidity ranged from 11.61 to 35.38 percent.
On 2/8/2013 the humidity ranged from 17.80 to 37.94 percent.
On 2/9/2013 the humidity ranged from 16.09 to 37.70 percent.
On 2/10/2013 the humidity ranged from 13.13 to 37.33 percent.
On 2/11/2013 the humidity ranged from 26.01 to 39.81 percent.
On 2/12/2013 the humidity ranged from 11.70 to 38.83 percent.
On 2/13/2013 the humidity ranged from 14.54 to 37.79 percent.
On 2/14/2013 the humidity ranged from 18.84 to 24.24 percent.
On 2/15/2013 the humidity ranged from 13.35 to 38.86 percent.
On 2/16/2013 the humidity ranged from 11.61 to 37.58 percent.
On 2/17/2013 the humidity ranged from 17.19 to 37.00 percent.
On 2/18/2013 the humidity ranged from 16.46 to 36.85 percent.
On 2/19/2013 the humidity ranged from 11.64 to 36.63 percent.
On 2/20/2013 the humidity ranged from 17.01 to 37.94 percent.
On 2/21/2013 the humidity ranged from 18.23 to 36.63 percent.
On 2/22/2013 the humidity ranged from 12.64 to 35.41 percent.
On 2/23/2013 the humidity ranged from 12.34 to 18.72 percent.
On 2/24/2013 the humidity ranged from 11.58 to 35.20 percent.
On 2/25/2013 the humidity ranged from 11.49 to 33.34 percent.
On 2/26/2013 the humidity ranged from 11.58 to 31.87 percent.
On 2/27/2013 the humidity ranged from 11.55 to 34.10 percent.
On 2/28/2013 the humidity ranged from 11.55 to 33.00 percent.
On 3/1/2013 the humidity ranged from 12.13 to 24.12 percent.
On 3/2/2013 the humidity ranged from 17.86 to 18.50 percent.
On 3/3/2013 the humidity ranged from 18.38 to 31.32 percent.
On 3/4/2013 the humidity ranged from 11.58 to 28.94 percent.
On 3/5/2013 the humidity ranged from 16.40 to 23.69 percent.
On 3/6/2013 the humidity ranged from 11.67 to 22.38 percent.
On 3/7/2013 the humidity ranged from 12.98 to 26.59 percent.
On 3/8/2013 the humidity ranged from 18.69 to 27.57 percent.
On 3/9/2013 the humidity ranged from 11.67 to 20.88 percent.
On 3/10/2013 the humidity ranged from 11.52 to 31.63 percent.
On 3/11/2013 the humidity ranged from 11.58 to 30.07 percent.
On 3/12/2013 the humidity ranged from 11.64 to 15.70 percent.
On 3/13/2013 the humidity ranged from 12.52 to 16.31 percent.
On 3/14/2013 the humidity ranged from 15.39 to 20.15 percent.
On 3/15/2013 the humidity ranged from 11.58 to 30.99 percent.
On 3/16/2013 the humidity ranged from 11.58 to 29.37 percent.
On 3/17/2013 the humidity ranged from 11.58 to 29.37 percent.
On 3/18/2013 the humidity ranged from 11.61 to 24.46 percent.

OR 2 - January
On 1/1/2013 the humidity ranged from 27.87 to 29.92 percent.
On 1/2/2013 the humidity ranged from 27.97 to 30.47 percent.
On 1/3/2013 the humidity ranged from 28.00 to 30.26 percent.
On 1/4/2013 the humidity ranged from 28.52 to 30.10 percent.
On 1/5/2013 the humidity ranged from 25.04 to 26.35 percent.
On 1/6/2013 the humidity ranged from 23.82 to 25.86 percent.
On 1/7/2013 the humidity ranged from 23.39 to 25.28 percent.
On 1/8/2013 the humidity ranged from 23.91 to 27.20 percent.
On 1/9/2013 the humidity ranged from 26.50 to 28.24 percent.
On 1/10/2013 the humidity ranged from 24.52 to 27.48 percent.
On 1/11/2013 the humidity ranged from 25.01 to 26.75 percent.
On 1/12/2013 the humidity ranged from 25.53 to 27.05 percent.
On 1/13/2013 the humidity ranged from 21.65 to 26.56 percent.
On 1/14/2013 the humidity ranged from 18.02 to 24.37 percent.
On 1/15/2013 the humidity ranged from 22.17 to 24.43 percent.
On 1/16/2013 the humidity ranged from 21.71 to 25.49 percent.
On 1/17/2013 the humidity ranged from 24.61 to 27.08 percent.
On 1/18/2013 the humidity ranged from 26.10 to 28.24 percent.
On 1/19/2013 the humidity ranged from 27.17 to 28.42 percent.
On 1/20/2013 the humidity ranged from 27.63 to 28.88 percent.
On 1/21/2013 the humidity ranged from 26.47 to 28.30 percent.
On 1/22/2013 the humidity ranged from 25.49 to 27.75 percent.
On 1/23/2013 the humidity ranged from 24.64 to 26.47 percent.
On 1/27/2013 the humidity ranged from 28.58 to 36.69 percent.
On 1/28/2013 the humidity ranged from 28.03 to 30.44 percent.
On 1/29/2013 the humidity ranged from 26.38 to 28.12 percent.
On 1/30/2013 the humidity ranged from 25.53 to 27.81 percent.
On 1/31/2013 the humidity ranged from 24.18 to 25.77 percent.
February -
On 2/1/2013 the humidity ranged from 24.76 to 26.29 percent.
On 2/2/2013 the humidity ranged from 24.52 to 26.04 percent.
On 2/3/2013 the humidity ranged from 23.57 to 25.07 percent.
On 2/4/2013 the humidity ranged from 23.33 to 26.20 percent.
On 2/5/2013 the humidity ranged from 24.82 to 26.59 percent.
On 2/6/2013 the humidity ranged from 23.14 to 28.15 percent.
On 2/7/2013 the humidity ranged from 18.78 to 26.01 percent.
On 2/8/2013 the humidity ranged from 23.08 to 26.26 percent.
On 2/9/2013 the humidity ranged from 23.24 to 26.68 percent.
On 2/10/2013 the humidity ranged from 22.60 to 26.14 percent.
On 2/11/2013 the humidity ranged from 22.23 to 26.47 percent.
On 2/12/2013 the humidity ranged from 23.85 to 28.09 percent.
On 2/13/2013 the humidity ranged from 23.51 to 26.78 percent.
On 2/14/2013 the humidity ranged from 22.41 to 23.57 percent.
On 2/15/2013 the humidity ranged from 21.89 to 24.95 percent.
On 2/16/2013 the humidity ranged from 24.15 to 26.65 percent.
On 2/17/2013 the humidity ranged from 26.01 to 27.33 percent.
On 2/18/2013 the humidity ranged from 25.04 to 27.39 percent.
On 2/19/2013 the humidity ranged from 24.21 to 27.23 percent.
On 2/20/2013 the humidity ranged from 24.18 to 26.78 percent.
On 2/21/2013 the humidity ranged from 26.26 to 27.75 percent.
On 2/22/2013 the humidity ranged from 18.51 to 28.18 percent.
On 2/23/2013 the humidity ranged from 16.16 to 17.93 percent.
On 2/24/2013 the humidity ranged from 15.00 to 16.74 percent.
On 2/25/2013 the humidity ranged from 15.85 to 17.56 percent.
On 2/26/2013 the humidity ranged from 14.54 to 18.11 percent.
On 2/27/2013 the humidity ranged from 16.28 to 17.65 percent.
On 2/28/2013 the humidity ranged from 15.85 to 17.16 percent.
March -
On 3/1/2013 the humidity ranged from 16.52 to 19.82 percent.
On 3/2/2013 the humidity ranged from 19.06 to 19.67 percent.
On 3/3/2013 the humidity ranged from 19.51 to 26.10 percent.
On 3/4/2013 the humidity ranged from 19.97 to 26.87 percent.
On 3/5/2013 the humidity ranged from 20.12 to 21.74 percent.
On 3/6/2013 the humidity ranged from 16.67 to 20.89 percent.
On 3/7/2013 the humidity ranged from 16.34 to 22.87 percent.
On 3/8/2013 the humidity ranged from 23.45 to 27.72 percent.
On 3/9/2013 the humidity ranged from 17.53 to 24.33 percent.
On 3/10/2013 the humidity ranged from 16.77 to 18.99 percent.
On 3/11/2013 the humidity ranged from 14.81 to 17.01 percent.
On 3/12/2013 the humidity ranged from 14.29 to 15.91 percent.
On 3/13/2013 the humidity ranged from 14.75 to 16.13 percent.
On 3/14/2013 the humidity ranged from 16.13 to 19.54 percent.
On 3/15/2013 the humidity ranged from 17.71 to 19.70 percent.
On 3/16/ 2013 the humidity ranged from 17.80 to 19.73 percent.
On 3/17/2013 the humidity ranged from 16.64 to 19.02 percent.
On 3/18/2013 the humidity ranged from 15.48 to 18.23 percent.

OR 3 - January -
On 1/1/2013 the humidity ranged from 16.39 to 32.20 percent.
On 1/2/2013 the humidity ranged from 17.33 to 31.68 percent.
On 1/3/2013 the humidity ranged from 18.74 to 31.34 percent.
On 1/4/2013 the humidity ranged from 16.51 to 32.90 percent.
On 1/5/2013 the humidity ranged from 16.82 to 31.01 percent.
On 1/6/2013 the humidity ranged from 17.30 to 31.92 percent.
On 1/7/2013 the humidity ranged from 17.73 to 32.04 percent.
On 1/8/2013 the humidity ranged from 23.07 to 29.24 percent.
On 1/9/2013 the humidity ranged from 24.32 to 29.45 percent.
On 1/10/2013 the humidity ranged from 16.05 to 31.56 percent.
On 1/11/2013 the humidity ranged from 15.63 to 30.58 percent.
On 1/12/2013 the humidity ranged from 24.45 to 29.72 percent.
On 1/13/2013 the humidity ranged from 22.61 to 27.25 percent.
On 1/14/2013 the humidity ranged from 15.69 to 27.95 percent.
On 1/15/2013 the humidity ranged from 15.14 to 31.89 percent.
On 1/16/2013 the humidity ranged from 14.68 to 30.21 percent.
On 1/17/2013 the humidity ranged from 13.73 to 29.51 percent.
On 1/18/2013 the humidity ranged from 13.46 to 28.87 percent.
On 1/19/2013 the humidity ranged from 15.63 to 28.32 percent.
On 1/20/2013 the humidity ranged from 15/05 to 27.95 percent.
On 1/21/2013 the humidity ranged from 17.43 to 29.48 percent.
On 1/22/2013 the humidity ranged from 14.19 to 30.21 percent.
On 1/23/2013 the humidity ranged from 15.05 to 30.88 percent.
On 1/27/2013 the humidity ranged from 18.77 to 32.99 percent.
On 1/28/2013 the humidity ranged from 15.87 to 29.51 percent.
On 1/29/2013 the humidity ranged from 17.61 to 28.84 percent.
On 1/30/2013 the humidity ranged from 18.77 to 28.60 percent.
On 1/31/2013 the humidity ranged from 18.77 to 31.25 percent.
February -
On 2/1/2013 the humidity ranged from 17.09 to 32.50 percent.
On 2/2/2013 the humidity ranged from 17.76 to 32.50 percent.
On 2/3/2013 the humidity ranged from 18.98 to 32.99 percent.
On 2/4/2013 the humidity ranged from 16.51 to 33.66 percent.
On 2/5/2013 the humidity ranged from 16.42 to 32.44 percent.
On 2/6/2013 the humidity ranged from 10.99 to 29.45 percent.
On 2/7/2013 the humidity ranged from 11.02 to 27.92 percent.
On 2/8/2013 the humidity ranged from 19.50 to 29.88 percent.
On 2/9/2013 the humidity ranged from 15.38 to 31.95 percent.
On 2/10/2013 the humidity ranged from 11.69 to 31.28 percent.
On 2/11/2013 the humidity ranged from 21.52 to 29.66 percent.
On 2/12/2013 the humidity ranged from 11.17 to 34.03 percent.
On 2/13/2013 the humidity ranged from 13.95 to 30.18 percent.
On 2/14/2013 the humidity ranged from 17.61 to 22.89 percent.
On 2/15/2013 the humidity ranged from 16.11 to 30.27 percent.
On 2/16/2013 the humidity ranged from 11.17 to 28.69 percent.
On 2/17/2013 the humidity ranged from 15.72 to 30.12 percent.
On 2/18/2013 the humidity ranged from 15.23 to 29.42 percent.
On 2/19/2013 the humidity ranged from 10.99 to 28.17 percent.
On 2/20/2013 the humidity ranged from 16.24 to 29.97 percent.
On 2/21/2013 the humidity ranged from 16.85 to 28.66 percent.
On 2/22/2013 the humidity ranged from 11.17 to 27.01 percent.
On 2/23/2013 the humidity ranged from 11.02 to 15.47 percent.
On 2/24/2013 the humidity ranged from 11.02 to 25.42 percent.
On 2/25/2013 the humidity ranged from 10.96 to 23.01 percent.
On 2/26/2013 the humidity ranged from 11.02 to 25.51 percent.
On 2/27/2013 the humidity ranged from 10.96 to 26.31 percent.
On 2/28/2013 the humidity ranged from 10.99 to 24.11 percent.
On 3/1/2013 the humidity ranged from 16.54 to 22.68 percent.
On 3/2/2013 the humidity ranged from 16.79 to 19.47 percent.
On 3/3/2013 the humidity ranged from 17.73 to 30.95 percent.
On 3/4/2013 the humidity ranged from 11.05 to 27.92 percent.
On 3/5/2013 the humidity ranged from 16.05 to 23.65 percent.
On 3/6/2013 the humidity ranged from 12.67 to 22.19 percent.
On 3/7/2013 the humidity ranged from 13.92 to 27.01 percent.
On 3/8/2013 the humidity ranged from 20.17 to 28.38 percent.
On 3/9/2013 the humidity ranged from 13.18 to 21.85 percent.
On 3/10/2013 the humidity ranged from 12.73 to 22.68 percent.
On 3/11/2013 the humidity ranged from 12.09 to 24.78 percent.
On 3/12/2013 the humidity ranged from 10.99 to 16.88 percent.
On 3/13/2013 the humidity ranged from 12.51 to 16.69 percent.
On 3/14/2013 the humidity ranged from 16.02 to 42.30 percent.
On 3/15/2013 the humidity ranged from 13.25 to 23.99 percent.
On 3/16/2013 the humidity ranged from 10.99 to 24.29 percent.
On 3/17/2013 the humidity ranged from 11.11 to 23.04 percent.
On 3/18/2013 the humidity ranged from 11.14 to 25.54 percent.