HospitalInspections.org

Based on document review and interview, in one (1) of six (6) grievance files reviewed, the hospital failed to implement its policy to ensure a written response was provided to the patient after investigation of the patient's grievance.

Findings include:

Review of the facility's Policy and Procedure titled "Patient Grievance and Complaint Mechanism", last revised 08/2018, states: "Complaints and grievances are to be investigated and timely addressed by staff, and the responsible clinical or administrative leader...The expectation is that most grievances will be resolved within 7 days, and that the Patient and Guest Relations Department will provide a written response to the complainant".

Review of the facility's Grievance Logs from January 2019 to January 2020 revealed that:
On 5/9/2018, the patient filed a grievance reporting that she was in the hospital to have a left cyst removed but a right ovarian cystectomy was performed. After the surgery on 5/7/18, she woke up in the recovery room with a left side abdominal pain, she was then informed by a nurse that the procedure was done on her right side. The grievance file revealed the case was closed on 5/17/2018.

There was no documented evidence that a written response on the outcome of the investigation was provided to the patient.

During an interview conducted with Staff D, Director of Regulatory Affairs, on 2/12/20 at 10:56 AM, she acknowledged that no final resolution was provided to the patient.
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Based on document review and interview, the facility failed to ensure that data collected on Relative Humidity (RH) in operating rooms were analyzed and corrective actions implemented.

Findings include:

Review of the Temperature and Relative Humidity (RH) logs for 2019 and 2020 revealed the RH in Operating Rooms (OR) was outside the range set by the hospital policy and procedure "20 % - 60 %". Examples included but were not limited to:

On 12/7/2019, the RH levels in OR #5 were 14.5%, 15.9% and 16.8 % at 12:00 midnight, 4:00 am and 6:00 am respectively.
On 12/7/2019, the RH levels in OR #7 were 18.0 %, 15.0 % and 10.8 % at 12:00 midnight, 4:00 am and 6:00 am respectively.

On 12/12/2019, the RH levels in OR #5 were 15.6%, 13.7% and 13.3% at 12:00 midnight, 4:00 am and 6:00 am respectively.

Similar findings regarding low RH levels below 20% were noted:
On 12/19/2019 for OR #s 5, 6 and 8;
On 01/09/2020 for OR #s 2, 5 and 11;
On 1/22/20 for OR #s 6 and 7;
On 01/30/20 for OR #s 6 and 7.

There was no documented evidence that action plans were implemented to correct the identified problem.

During interview with Staff G, Assistant Vice President of Surgical Services on 2/12/20 at 1:30 PM, she acknowledged findings.
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Based on observation and staff interview, the facility failed to ensure that the Operating Rooms (OR) were constructed and maintained in a manner that help prevent and control the transmission of infections within the hospital.

Findings include:

During tours of the Operating Rooms of the hospital on the 2/11 and 2/12/2020, the following were identified in the presence of the Assistant Vice President (AVP) of Surgical Services:

The ceiling tiles of the operating rooms were not a monolithic (consisting of one piece; solid or unbroken) ceiling as required by Facility Guidelines Institute (FGI) 2010 guidelines. The ceiling tiles in many of the Operating Rooms had gaps and crevices that can harbor mold and bacterial growth which makes it difficult to clean them.

Similar findings were noted in many operating rooms; examples included but were not limited to OR #3, OR#4, OR#8 and OR#9.

As per FGI 2010 edition; (a) Ceilings in restricted areas (e.g., operating rooms) shall be of monolithic construction. Cracks or perforations in these ceilings shall not be permitted.
(b) Ceiling finishes shall be scrubbable and capable of withstanding cleaning and/or disinfecting chemicals.
(c) All access openings in these ceilings shall be gasketed.

2. Some scrub sinks were not functioning and did not have water, and some scrub sinks did not have the proper hot water temperature i.e., 110-degree Fahrenheit (F) to 120 F. as required by Center for Disease Control and Prevention (CDC) Guideline for Handwashing and Hospital Environmental Control;
Examples included but were not limited to:
Scrub sink by OR #8 had a water temperature of 70 F.
Scrub sink by OR #s 1 and 2 was not functioning.
Scrub sink by OR #s 11 and 12 had a water temperature of 100 F.
Scrub sink by OR #6 had a water temperature of 101 F.

3. The 'Appllo' Anesthesia machine in OR #9 did not receive the required annual maintenance and was overdue for the annual biomed check. The last biomed check was done in May 2018.

4. The surface of the surgical table in OR #9 was torn. The torn upholstery can potential harbor germs and make it difficult for proper disinfection of the surgical table.

5. Interviews with Staff G, AVP Surgical Services revealed that the 'Davinci Si' Surgical System that was installed in OR #9 was out of service and has not been used since September 2019. There was no indication that this equipment had been disinfected/cleaned before or after surgical procedures. This finding was verified with Staff G, AVP of Surgical Services on 2/12/20 at 11:30 AM.

6. There were many broken floor tiles and some rusted floor tiles observed in the clean section of the central sterile area. Broken floor tiles can collect germs and dust which makes the floor tiles difficult to properly disinfect and clean.

7. OR #10 was used as storage for equipment and combustible materials, which is potential fire hazard.
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Based on observation, document review and staff interview, the facility failed to maintain an acceptable range of Relative Humidity (RH) in accordance with its policy and procedures and generally acceptable standards of practice.

This failure increases the chance of electrostatic discharge that may result in fire

See A0941.
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Based on observation, document review and staff interview, the facility failed to maintain an acceptable range of Relative Humidity (RH) in accordance with its policy and procedures and generally acceptable standards of practice.

This failure increases the chance of electrostatic discharge that may result in fire

Findings include:

Review of Facility Guidelines Institute (FGI) 2010 notes that the acceptable range of Relative Humidity (RH) is between 30-60%. "Low Relative Humidity increases the chances of electrostatic discharge that could harm or interfere with electromedical equipment, and potentially spark a fire, which may cause fire in the operating rooms due to lack of proper humidity, enriched oxygen atmosphere, flammable anesthetics and presence of ignition sources; curtery or laser use."

Review of facility policy and procedure titled "Temperature & Humidity Monitoring for Operative and Anesthetizing Procedure Area" last revised 03/2019, notes the facility, "in accordance with the Center for Medicare & Medicare (CMS) memorandum ... has elected to use the Life Safety Code (LSC) waiver provision for permitting new and existing ventilation systems to operate with a RH of 20% to 60% in all facilities having anesthetizing locations ... If the temperature and/or the humidity are not within the designated parameter on an area/room a risk assessment will be conducted ... when the temperature and humidity is elevated the procedure should be delayed until within designated parameters. If the physician designates the case is emergent the case should proceed and documented as emergent."

The referenced CMS memorandum dated April 19, 2013 notes "Facilities must monitor RH in anesthetizing locations and take corrective actions when needed to ensure RH remains at or above 20%.

Review of the Temperature and Relative Humidity (RH) logs for 2019 and 2020 revealed the RH in Operating Rooms (OR) was outside the range set by the hospital policy and procedure "20 % - 60 %". Examples included but were not limited to:

On 12/7/2019, the RH levels in OR #5 were 14.5%, 15.9% and 16.8 % at 12:00 midnight, 4:00 am and 6:00 am respectively.
On 12/7/2019, the RH levels in OR #7 were 18.0 %, 15.0 % and 10.8 % at 12:00 midnight, 4:00 am and 6:00 am respectively.

On 12/12/2019, the RH levels in OR #5 were 15.6%, 13.7% and 13.3% at 12:00 midnight, 4:00 am and 6:00 am respectively.

Similar findings regarding low RH levels below 20% were noted:
On 12/19/2019 for OR #s 5, 6 and 8;
On 01/09/2020 for OR #s 2, 5 and 11;
On 1/22/20 for OR #s 6 and 7;
On 01/30/20 for OR #s 6 and 7.

Review of the facility's document titled "Temperature and Humidity Risk Assessment Tool" indicated that the tool must be completed prior to the start of the surgical procedure, when temperature or humidity is out of acceptable range. (Temperature below 67 F or above 76 F; humidity below 19 or above 61%).

There were instances when the ORs were outside the parameters of humidity and the decision was made to proceed with planned surgery.
Examples included but were not limited to:

On 12/12/2019, OR #s 5 and 7 had "Temperature and Humidity Risk Assessment Tool" completed for RH levels of 13.2 % and 5.2 % respectively. The decision was made to proceed with planned surgery despite the lower humidity level in both rooms.

On 12/19/2019, OR #s 5 and 6 had risk assessment tools completed for RH levels of 11.4 % and 16.3% respectively. The decision was made to proceed with planned surgery despite the lower humidity level in both rooms.

On 12/20/2019, OR #6 and OR #7, the decision was made to proceed with planned surgery despite the lower humidity level in both rooms. Relative Humidity were 16.4 % and 16.5% respectively.

The documentation in the "Temperature and Humidity Risk Assessment Tool" did not indicate that these cases were emergent. In addition, the risk assessment tool did not document who was involved in the risk assessment and the justification for using the ORs when RH levels were outside the range indicated on the risk assessment tool.

During interview with Staff G, Assistant Vice President of Surgical Services on 2/12/20 at 1:30 PM, she acknowledged findings.