HospitalInspections.org

Based on observation, interview, document review, environmental testing results, and policy review, the facility failed to meet the Condition of Participation (CoP) for Physical Plant and Environment respective to applicable CoPs under 42 CFR 482.41. The facility failed to ensure areas of probable mold, first identified in a 10/30/23 mold spore testing report, were managed according to a mold remediation plan dated 01/30/24 in multiple public and patient care units resulting in visible mold around windows and on ceiling tiles. This failure increased the risk of a new onset of respiratory and skin conditions, the exacerbation of chronic asthma/ bronchitis, and other long term health problems. patients, staff, and/or visitors of the hospital as mold spores carry with air movement.

Findings include:

1. The facility failed to act when visible mold was identified as an ongoing issue. Refer to A-0701.

Based on observation, record review, and interviews, the facility failed to meet the Condition of Participation (CoP) for Infection Prevention and Control respective to the applicable CoPs under 42 CFR 482.42 for one patient (Patient (P) 15 out of a sample of 42 patients reviewed. The facility failed to ensure a plan for alternate placement for dialysis access was developed and implemented which increased the risk of potential infection, sepsis, and possible death.

Findings include:

1. The facility failed to ensure a new hemodialysis patient P15, admitted on 02/03/25, with a tunneled central venous catheter hemodialysis access placed on 02/10/25, received the vein mapping and alternate access (arteriovenous graft (AVG) or fistula (AVF) placement even after an inpatient stay of greater than six months. Refer to A-0776.

Based on record review, interview, and facility policy review, the facility failed to ensure a patient (Patient (P) 23) was monitored per protocol while in the Emergency Department. This failure had the potential for changes in condition not to be identified and treatment provided.

Findings include:

Review of the facility policy titled "Fundamental Standards of Care in the Emergency Department," reviewed 10/2024, revealed:
"Policy: Fundamental Emergency Department nursing interventions include, but are not limited to the following:
ESI [Emergency Severity Index] Acuity Level 1: Vital signs every 5-15 minutes and/or unless ordered more frequently
ESI Acuity Level 2 &3 : Vital signs every 30-60 minutes and/or unless ordered more frequently
ESI Acuity Level 4 & 5: Vital signs every 60-120 minutes and/or unless ordered more frequently"

Review of P23's record showed an admission to the hospital on 08/03/25 and discharge on 08/05/25 after being seen in the Emergency Department.

Review of the Emergency Department (ED) "Nursing Chart" with Clinical Nurse Informatics Specialist (CNIS) showed an arrival to the ED at 6:22 PM on 08/03/25 after a near drowning incident and the triaged acuity was "1 (Resuscitation)." P23's vital signs were taken at:
6:22 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
10:37 PM
CNIS stated on 08/09/25 at 10:49 AM stated P23 was "ESI 1" and there was no order for less frequent vital signs. CNIS stated perhaps there were manual vital signs and would check the other charting documentation.

During an interview on 08/12/25 at 2:40 PM regarding additional vital sign documentation for P23, the Administrator, Quality, Patient Safety & Regulatory Compliance (AQPSRC) stated she had "checked the documentation and even on manual form, the protocol for frequency [of vital signs] would have been non-compliant."

Based on observation, interview, and checklist review, the facility failed to ensure expired medications and vacutainers (for blood collection / testing) were not in the emergency department "Malignant Hyperthermia" response cart. This failure had the potential to affect a successful outcome in an emergent event.

Findings include:

Observation of the Emergency Department (ED) "Malignant Hyperthermia" (MH, a potentially fatal genetic condition that causes a rapid body temperature increase with muscle contracture triggered by certain anesthetics) cart on 08/05/25 at 1:06 PM revealed four pediatric sized vacutainer blood tubes with an expiration date of 06/20/25. The Emergency Department Manager (EDM) confirmed the expiration date on the tubes at 1:08 PM.

Further observation of the "Malignant Hyperthermia" cart revealed two 2% lidocaine injectable 100 milligram in 5 milliliters (5mg/5mL) with an expiration date of 08/01/25; confirmed by the Deputy Assistant Nursing Services (DANS) on 08/05/25 at 1:10 PM. A policy regarding medications was requested.

Review of the facility "Malignant Hyperthermia Cart Monthly Checklist Month of: August 2025" showed "2% Lidocaine 5ml Inj [injection]," handwritten 100mg with a quantity of "2" and an expiration date handwritten of "9/1/25 & 9/25." The form was not dated when the checklist was completed, just had a handwritten "Expired 8/31/25/[signature of RN1]."

A policy was not received. Review of the Association of Peri-Operative Registered Nurses (AORN) website regarding "Best Practices for MH Crisis Response" (https://www.aorn.org/outpatient-surgery/article/best-practices-for-mh-crisis-response) revealed "Deeper quarterly inspections of your MH cart should include checking for missing or expired medications ..."

Review of the Joint Commission "Crash Cart Preparedness," issued April 2017, stated:
" ...Contributing factors to patient safety events related to crash carts include, but are not limited to:
Medication errors and mix-ups
Missing, expired, damaged, contaminated, and unavailable equipment or medications"

Based on observation, interview, and policy review, the facility failed to ensure proper handling of bakeware and failed to ensure a cook contained facial hair while in the kitchen. These failures had the potential to have bacteria grow in the bakeware or contaminate food with facial hair.

Findings include:

During the observation of the kitchen on 08/06/25 at 1:50 PM, the Dietary Manager (DM) picked up a stack of eight quarter sheet pans and water streamed out from the stack, indicative that the pans were turned upside down and stacked while still wet; at another shelf, the DM lifted two full size steam table pans to reveal water droplets between the pans. The DM confirmed they had not been fully air-dried before stacking. At 2:10 PM, Cook 1 was observed preparing food with uncontained facial hair. When asked about it, the DM identified him, confirmed he did not have a facial hair cover, and immediately went over to Cook 1 and advised him to cover his facial hair.

During an interview on 08/12/25 at 3:18 PM, the Administrator, Quality, Patient Safety & Regulatory Compliance (AQPSRC), provided the policy below stating, "they can't have facial hair" and stated there was no policy regarding the wet-stacking but that it was in the Public Health regulations.

Review of the facility "Dietic Services Department" policy titled "Professional Image and Hygienic Practices," effective 09/30/21, revealed:
"Procedure:
1. General Principles
A. General Dress Code ...
3. Hair should be neat and clean. Sideburns are allowed and must be well trimmed. Mustaches and beards are not permitted."

Review of the "Guam Food Code," (https://dphss.guam.gov/wp-content/uploads/2019/05/Guam-Food-Code-with- revealed:
Drying 4-901.11 Equipment and Utensils, Air-Drying Required.
Items must be allowed to drain and to air-dry before being stacked or stored.
Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils.
Storing 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. . . .
(B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored:
(1) In a self-draining position that allows air drying . . . "

Based on observation, interview, document review, environmental testing results, and facility policy review, the facility failed to ensure areas of probable continued mold, first identified in a 10/30/23 mold spore testing report were managed according to a mold remediation plan dated 01/30/24 in multiple public and patient care units, along with other environmental issues. The effect of the deficient practices in environmental containment with mold throughout the hospital due to the ongoing water and moisture issues, visible mold around windows and on ceiling tiles, could potentially jeopardize the health and safety of any patients, staff, or visitors of the hospital as mold spores carry with air movement.

Findings include:

During the facility tour on 08/05/25 at 1:50 PM by door "EMB 295B/CDR1," in between the surgical area and labor and delivery units, moisture, black areas, and cobwebs were noted around the window frames and walls. At 2:07 PM, exiting the nursery area, the cove base was noted to be held together with tape by Door EM-C270B. The Administrator, Quality, Patient Safety & Regulatory Compliance (AQPSRC) confirmed the presence of mold, moisture, cove base taping, and cobwebs. Numerous areas of the hospital had wet floor signs on the floor with blue material on the floor near the sign to absorb water, first observed through the doors to enter the elevator commons area.

During the facility tour of the third floor on 08/06/25 at 12:05 PM the ceiling tiles outside the Medical/Surgical department had black circular growths with an additional three tiles noted with a black substance down the hall, with one ceiling tile appeared wet; the AQPSRC confirmed the moisture related areas. Continuing on the third floor to the Telemetry unit at 2:20 PM, broken ceiling tiles and tiles with a black substance were observed and confirmed by the AQPSRC. On to the fourth floor at 2:28 PM, outside the pediatric unit doors, stained and buckling ceiling tile were observed; inside the unit doors broken ceiling tiles, stained ceiling tiles and dark areas next to a sprinkler head; in the playroom area, the ceiling tiles were water stained but not currently wet. During the tour of the surgical unit at 2:40 PM, the output ceiling vent (air flow noted from the vent) by the nurse's station was noted to have dark streaking and dust buildup; an intake ceiling vent (no airflow noted) outside of patient rooms 437/438 was noted to have fuzzy black dots on the metal. Outside of patient room 433 the drywall was noted to be buckling with a blue absorbent cloth on the floor along the cove base and in the patient room bathroom one of the tiles at the bottom near the floor under the sink on the outside of the shower was missing (appeared to be eroded) and was no longer secured to the wall; outside of room 419 there were five water stained ceiling tiles; the cove base was detached away from the wall in room 417 and four ceiling tiles had water damage; and two ceiling tiles outside of room 418 were water stained. All observations were confirmed by the AQPSRC on the tour.

Review of the facility provided "Indoor Air Quality/Airborne Mold Spore Testing Report," dated 10/30/23, revealed:
"Results ...
Based on the visual inspection, mold growth and signs of water intrusions/water leaks were observed throughout the inspected areas as well as the hallways throughout the building. According to facility management personnel, ceiling tiles are regularly changed out when potential old growth is observed. However, in conjunction with the high relative humidity throughout the building, if the source(s) of water intrusions/water leaks are not properly addressed, mold will continue to proliferate throughout the building."

Review of the facility provided "Typhoon Mawar Mold Remediation Plan of Corrective Action," dated 01/30/24, revealed:
" ...Intermediate POC (3 - 9 months post typhoon passage) ...
-Continue monitoring for and detection of visible mold; and perform visible mold cleaning on floors/walls/doors/surfaces and replace visibly moldy ceiling tiles."

During an interview on 08/07/25 at 8:55 AM regarding the observed mold, the Plant Manager (PM) stated, "It's because of the dripping condensation from the water lines." When asked if they were aware of the issue, the PM stated, "we have a PIP [performance improvement plan] for the HVAC system, was supposed to be replaced by December 2023, but I believe we are still looking for funding." When shown pictures of the ceiling tiles with the black substances, the PM confirmed it was mold. When queried about the mold mitigation plan frequency of monitoring, the PM responded, "We go around daily." When asked if there were any logs of the monitoring, the PM said there were no logs and confirmed he had no idea how long the ceiling tiles had been there and was unaware of the last time it was checked. "We're the one [responsible] for public areas. Sometimes work orders are placed and sometimes we just replace it."

Review of the facility provided "Environment of Care Committee" minutes revealed:
09/26/24 "I. Utilities Management. . .Performance Standards . . . Mold monitoring: 69 specific locations monitored (GMH 47 and SNF [Skilled Nursing Facility] 22). 16 at GMH ...were not in recommended range."
12/05/24 "I. Utilities Management. . .Performance Standards . . . Mold monitoring: 69 specific locations monitored (GMH 47 and SNF 22). 10 at GMH ...were not in recommended range."
01/03/25 "I. Utilities Management. . .Performance Standards . . . Mold monitoring: 69 specific locations monitored (GMH 47 and SNF 22). 10 at GMH ...were not in recommended range."
02/27/25 "I. Utilities Management. . .Performance Standards . . . Mold monitoring: 69 specific locations monitored (GMH 47 and SNF 22). 10 at GMH ...were not in recommended range."
04/01/24 "I. Utilities Management. . .Performance Standards . . . Mold monitoring: 69 specific locations monitored.
GMHA 8 out of the 47 locations are not in the recommended range. . . .
06/26/25 "6. Facilities Maintenance
b) Utilities Management
-Indoor Air Quality (IAQ) . . .
Mold Monitoring Results
GMHA: 12 out of 47 failed . . ."

Review of the facility policy titled "Water Infiltration, Flooding and Sewer Backup Response," revised 03/2010, revealed:
" ...V. Area Cleanup [sic]
Water damaged building materials and furnishings, if not appropriately handled, can become significant sources of microbiological contamination. This is true even if the water damage occurs from exposure to clean water.
...B. Remove all wet ceiling tiles, bag them, and place in the regular trash."

Based on observation, interview, and policy review, the facility failed to ensure patient equipment was maintained in a manner to allow for/maintain disinfection. This failure had the potential to subject patients to cross contamination which could result in healthcare acquired infections. The survey census was 149.

Findings include:

1. Observation of operating room 3 on 08/07/25 from 9:50 AM to 11:40 AM revealed the two IV stand bases by the anesthesia area, the trash bag rolling carts, and over bed table (used by nurse for charting) had rusted, uncleanable surfaces.

During an interview on 08/07/25 at 11:44 AM, the Administrator, Quality, Patient Safety & Regulatory Compliance (AQPSRC) confirmed the presence of rust on the identified surfaces.

Observation of operating room 1 on 08/07/25 at 12:20 PM revealed the presence of rust on the rolling trash bag cart, IV pole stand, and around the window.

During an interview on 08/07/25 at 12:42 PM, the AQPSRC confirmed the presence of rust on the identified surfaces.

2. During the observation of endoscopic equipment cleaning on 08/07/25 at 11:45 AM, a clean scope was noted to be hanging (done to drain any residual water from the scope) open to the air at the end of the table where the scope rinsing was done. At the time of this observation, a dirty scope was being processed in the open sink in the room.

During an interview on 08/07/24 at 11:47 AM, Medical Equipment Tech (MET) 1 and MET2 confirmed the hanging scope had been disinfected.

3. During the laboratory tour on 08/08/25 at 12:20 PM, an observation of the laboratory patient blood station on 08/08/25 at 12:24 PM revealed the upholstered arm rest (where a patient would rest their arm for tourniquet application, site cleaning, and blood sample draw) revealed an open area with exposed foam padding. A rusty table was observed in the chemistry processing area and rust was observed on cabinet doors below the sink in the histology area.

During an interview on 08/08/24 at 12:24 PM, the Lab Manager confirmed the chair was used for blood draws of patients and at 12:40 PM and 12:45 PM the AQPSRC confirmed the presence of the rust in the chemistry and histology areas.

Review of the facility policy titled "Environmental Maintenance (EM) Program," approved 04/28/22, revealed:
"Purpose:
The purpose of this policy is to describe and outline the process by which maintenance work within defined environmental units is assigned, performed, and documented.
Policy:
1. The Hospital will maintain its physical plan in accordance with a recommended schedule that will serve to provide a safe, functional, and aesthetically pleasing environment. . . .
Attachment 1
Items Included in Environmental Maintenance
...Bedside Tables
...Counters/Closets/Chairs
...Sinks
...Windows"

Review of the facility policy titled, "Guidelines for Environmental Infection Control," effective date 03/17/23, revealed:
"Purpose: Our hospital must manage its environment (to include utilities, surfaces, medical devices) in a way to reduce potential risks of hospital associated infections and transmission of infections. This policy provides guidelines for management of the environment to reduce those risks associated with air handling and ventilation systems, water distribution systems, housekeeping, laundry, and service animals. . . .
XIII. Carpeting and Cloth Furnishings
...C. Avoid using upholstered furniture and furnishings in high-risk patient-care areas and in areas with increased potential for body substance contamination . . .
D. Maintain upholstered furniture in good repair.
A. Maintain the surface integrity of the upholstery by repairing tears and holes."

Review of the facility policy titled "Guidelines for High Level Disinfection of Semi-Critical Devices Using Medline OPA/28 Solution, Leak Testing, Quality Control Testing, Neutralization for OPA Disposal, and OPA Spills," reviewed 09/2023, revealed:
" ...XVI. Post-Processing Handling and Storage of Reusable Devices: Disinfected reusable devices are either to be immediately used or stored in a manner to minimize recontamination. . . ."

Based on observations, record review, and interviews, the facility failed to ensure alternate forms of access were provided to reduce the risks of tunneled central venous catheter (CVC) infection for one patient (Patient (P) 15) out of a total sample of 42 patients reviewed. This failure resulted in a tunneled CVC being in place for dialysis access for six months with no plans for placement of an alternate vascular access.

On August 11, 2025, at 8:15 PM, an Immediate Jeopardy (IJ) situation was declared in the presence of the hospital Administrator, Quality Patient Safety & Regulatory Compliance (AQPSRC) after the Centers for Medicare and Medicaid Services (CMS) agreed to the IJ through surveyor observations, interviews, and record review. The hospital failed to protect one identified patient at risk for infection, sepsis, and potential death from a long-term use of a tunneled CVC.

On August 13, 2025, at 4:52 PM, the Immediate Jeopardy situation was removed via email with the AQPSRC. The facility was informed that the hospital's Removal Plan was approved and implementation was verified as effective on 08/13/25 at 4:52 PM upon completion of 80% staff / practitioner education was achieved.

Findings include:

During an interview on 08/09/25 at 11:35 AM, P15 stated the hospital hemodialysis nurses were asking him about having the CVC for six months. When asked if he had completed the vein mapping for alternate access placement, P15 responded "No" and stated he did not know what the plans were and he was confused by the nurses asking about having the CVC for six months.

Review of P15's medical record "Consultation Sheet" showed an admission date of 02/03/25 and the Nephrologist documented on 02/03/25 at 9:46 PM
"Plan: Rec [recommend] Quinton Cath Placement
HD tomorrow 1st Rx [first prescription for dialysis]
Recommend to place Permacath [tunneled CVC]
Consult Surgery for AVF placement while IP [In Patient], as he has good veins."

During interviews on 08/11/25 at 10:18 AM and 11:14 AM, Medical Doctor (MD)1 and MD2 (both nephrologists that have seen P15), confirmed the discharge of a patient with a Central Venous Catheter (CVC) increased the risk of infection. MD1 stated the discharge of a patient with a CVC increased the risk of infection and death by 50% (due to the Guam environment and socioeconomic issues). Both doctors noted vein mapping and alternate site placement changed to an "elective procedure" during the COVID pandemic and have remained classified as elective procedures even though the Public Health Emergency (PHE) ended in May of 2024.

During an interview on 08/11/25 at 11:14 AM, the Chief Medical Officer (CMO) stated he completed 90% of the fistulas/grafts on the island but vein mapping must be done first. The CMO related he had not received a consultation for in-patient AVG/AVF placement since the end of the PHE and 100% of patients leave with a catheter because they (hospital departments) do not allow it. The CMO stated, "Patients sent home with a CVC [tunneled] because of the environment in Guam, survival of dialysis patients decrease by 50%. It will take more than three months to place [AVF/AVG] and three months to mature; more than six months has shown to decrease survival. I see infected [tunneled catheters] because they [patients] come back to the hospital with readmissions. Fistulas and grafts do better. [Vein] Mapping and placement [AVF/AVG] are lifelines, but they [hospital departments] say they are elective [procedures]."

During an interview on 08/11/25 at 3:10 PM, the Hemodialysis Unit Supervisor (HDUS) stated, "The use of a Permacath [tunneled CVC for dialysis] goal is three months or less. However, because most of their patients do not stay that long [in the hospital], there is no policy [for long term use of CVC]"

The facility provided a list of 30 patients discharged with a CVC in the past six months. During an interview on 08/11/25 at 6:14 PM, the Infection Preventionist verified that two of the patients discharged with a CVC in the past six months were known to have had CLABSI (Central Line-Associated Blood Stream Infection) making the CLABSI rate 6.67%.

Based on observations, interviews, and record reviews, the hospital failed to provide surgical services in a well-organized manner, in accordance with the hospital's own policies, acceptable national standards of practice, and in a manner to prevent the risk of cross contamination (the transfer of harmful bacteria from one person, object, or place to another), when 1. one of two surgical pre-procedure time-outs did not address the fire risk for one patient (Patient (P) 3) out of a sample of 42 residents reviewed and 2. the facility failed to ensure documentation of intervention or closure of surgical suites when the temperatures and/or humidity levels were not within the correct range.

Findings include:

1. The hospital did not ensure a fire risk assessment was conducted prior to a fluoroscopy scope procedure for one of two sampled surgical patients P 3.

Review of P3's "Operative/Invasive Procedure Verification Checklist" form, revealed the patient procedure was for a "Repeat endoscopic retrograde cholangiopancreatography [procedure to examine the bile ducts, pancreatic duct, and related structures]," dated and signed 08/06/25 at 6:35 AM.

Observation of P3's procedure on 08/07/25 at 10:05 AM revealed the pre-procedure "Time-Out" did not address the patient's fire risk.

During an interview on 08/07/25 at 11:57 AM, the Surgical Manager (SM) and Administrator, Quality, Patient Safety & Regulatory Compliance (APQSRC) both confirmed the surgical pre-procedure time-out did not address the fire risk and should have.

Review of the facility policy titled "Patient Safety in Anesthetizing Locations," "Interim Approved May 02, 2019," revealed:
" ...VI. Prevention of burns/ fires: . . .
6. The Surgical team shall conduct a "time out" before the start of surgery to ensure:
a. The surgical site shall be dry before draping and before the use of the electrosurgical unit, cautery, and/or laser.
b. There shall be no pooling of the prep solution around the patient"

Review of the Association of peri-Operative Registered Nurses (AORN) website (https://www.aorn.org/article/the-importance-of-the-fire-risk-assessment) revealed:
"A fire risk assessment should be done prior to the start of every case, and the fire risk should be discussed with the entire surgical team during the time out. This will keep everyone aware of how elevated the risk for a fire is during each procedure and what aspects of the procedure the risks are coming from, both of which can help prevent a fire from happening. Staff should also have, at a minimum, yearly fire safety education. This will give staff direction as to what to do should a fire start. A properly trained, quick-thinking surgical team can make all the difference in the event of an OR fire."

Review of the National Institute of Health (NIH) (https://www.ncbi.nlm.nih.gov/books/NBK544303/) revealed:
"Nursing, Allied Health, and Interprofessional Team Interventions
An interprofessional team approach is required to prevent the outbreak of a surgical fire. Good communication between all the OR members is a must. Surgical time-out is the most critical time point for detailing all the sources of fuels, oxidizers, and specific ignition sources within a procedure."

2. Review of the "Temperature and Humidity Tracking Log Sheet for Operating Rooms" (different pages for each room) revealed at the top of the page, before the "Month" was handwritten in, was "Normal Ranges: Temperature: 68oF [Fahrenheit] to 75oF" and "Normal Ranges: Humidity: 30 - 60%." The page had two columns, titled "AM 07-15 [7:00 AM - 3:00 PM] Shift" and "PM 15 - 23 [3:00 PM - 11:00 PM" with the dates prefilled and blank columns for the "Temperature," "Humidity," and an "Initial" column. At the bottom of each log was a box that stated "If temperature or humidity is out-of-range, contact Facilities Management (FM) at [phone number] on regular workdays or [phone number] on weekends, holiday and after hours. If unable to contact FM, call Communication Center [phone number]. Log ALL corrective actions on the back side of this form." The back side of the form had boxes for which was out-of-range, the FM notification date and time, the name of the FM Personnel notified, who notified them, the corrective action taken, the FM actions taken by who, date, time; and if the problem was rectified (Yes/No) and who concurred with the rectified status.

Review of the log sheets for "Operating Room Suite 1," April 2025, revealed:
6 of 30 days the AM temperatures were below the minimum temperature with no documentation of FM notification, corrective actions, or Operating Room (OR) closure.
1 of 30 days the PM temperature was below the minimum temperature; and one day was crossed out with no other data input, with no documentation of FM notification, corrective action, or OR closure.

For May 2025, the log sheets revealed:
13 of 31 days the AM temperatures were below the minimum temperature and 2 of 31 days the humidity was above the maximum allowed, with no documentation of FM notification corrective action, or OR closure.
3 of 31 days the PM temperatures were below the minimum temperatures and 2 of 31 days the humidity was above the maximum allowed, with no documentation of FM notification, corrective action, or OR closure.

For June 2025, the log sheets revealed:
14 of 30 days the AM temperatures were below the minimum temperatures and 3 of 30 days the AM humidity levels were above the maximum allowed with no documentation of FM notification, corrective action, or OR closure.
1 of 30 days the PM temperature was below the acceptable level with no documentation of FM notification, corrective action, or OR closure.

For July 2025, the log sheets revealed:
22 of 31 days the AM temperatures were below the minimum temperatures with no documentation of FM notification, corrective action, or OR closure.
1 of 31 days the PM temperatures was below the minimum temperature with no documentation of FM notification, corrective action, or OR closure.

Review of the log sheets for "Operating Room Suite 2" April 2025 revealed:
18 of 30 days the AM temperatures were below the minimum temperatures and two of 30 days the humidity was above the acceptable level with no documentation of FM notification, corrective action, or OR closure.
One of 30 days the PM temperature was below the minimum temperature allowed, one had no documentation at all, and three of 30 days the humidity was above the maximum humidity allowed with one date having no documentation, with no documentation of FM notification, corrective action, or OR closure.

Review of the May 2025 log sheets revealed:
13 of 31 days the AM temperatures were below the minimum temperatures and one of 31 days the humidity was above the maximum allowable with no documentation of FM notification, corrective action, or OR closure.
Six of 30 days the PM temperatures were below the minimum temperatures with no documentation of FM notification, corrective action, or OR closure.

Review of the June 2025 log sheets revealed:
13 of 30 days the AM temperatures were below the minimum temperatures with no documentation of FM notification, corrective action, or OR closure.
Five of 30 days the PM temperatures were below the minimum temperatures with no documentation of FM notification, corrective action, or OR closure.

Review of the July 2025 log sheets revealed:
24 of 31 days the AM temperatures were below the minimum temperatures, and one of 31 days had a humidity level above the acceptable level with no documentation of FM notification, corrective action, or OR closure.
Three of 31 days the PM temperatures were below the minimum temperatures with no documentation of FM notification, corrective action, or OR closure.

Review of the log sheets for "Operating Room Suite 3" April 2025 revealed:
14 of 30 days the AM temperatures were below the minimum temperature, one of 30 days the temperature was above the maximum temperature with no documentation of FM notification, corrective action, or OR closure.
3 of 30 days the PM temperatures were below the minimum temperature with no documentation of FM notification, corrective action, or OR closure.

Review of the May 2025 log sheet revealed:
12 of 31 days the AM temperatures were below the minimum temperature, one of 31 days the temperature was above the maximum temperature; and two of 31 days the humidity level was above the maximum level allowed with no documentation of FM notification, corrective action, or OR closure.
Four of 31 days the PM temperatures were below the minimum temperature, one of 31 days the temperature was above the maximum temperature, and two of 31 days the humidity level was above the maximum allowable with no documentation of FM notification, corrective action, or OR closure.

Review of the June 2025 log sheet revealed:
15 of 30 days the AM temperatures were below the minimum temperature with no documentation of FM notification, corrective action, or OR closure.
Five of 30 days the PM temperatures were below the minimum temperature, and one of 30 days the humidity was above the maximum allowable with no documentation of FM notification, corrective action, or OR closure.

Review of the July 2025 log sheet revealed:
22 of 31 days the AM temperatures were below the minimum temperature, and one of 30 days the humidity was above the maximum humidity with no documentation of FM notification, corrective action, or OR closure.

Review of the log sheets for "Operating Room Suite 4" April 2025 revealed:
Eight of 30 days the AM temperatures were below the minimum temperature with no documentation of FM notification, corrective action, or OR closure.
Four of 30 days the PM temperatures were below the minimum temperature with no documentation of FM notification, corrective action, or OR closure.

Review of the May 2025 log sheet revealed:
Six of 31 days the AM temperatures were below the minimum temperature and one of 31 days humidity was above the maximum allowable humidity with no documentation of FM notification, corrective action, or OR closure.

Review of the June 2025 log sheet revealed:
11 of 30 days the AM temperatures were below the minimum temperature with no documentation of FM notification, corrective action, or OR closure.
One of 30 days the PM temperature was below the minimum temperature with no documented FM notification, corrective action, or OR closure.

Review of the July 2025 log sheet revealed:
15 of 31 days the AM temperatures were below the minimum temperature with no documented FM notification corrective action, or OR closure.

During an interview on 08/08/25 at 9:54 AM regarding documentation of interventions, the SM stated she was aware of the out-of-range values but "I have no documentation of the room corrective actions on most of the days. There is an issue with form [not being completed] and I need to re-educate the staff." SM provided email work orders for one room humidity level, dated and responded to by FM 05/28/25; one for humidity level dated 06/02/25 and responded to by FM on 06/13/25; and one dated 06/11/25 responded to by FM on 06/14/25 for the recovery room.

A review of the hospital's Policy and Procedure titled "Air Control in the OR," reviewed 08/2021, revealed:
"Policy:
Temperature of the operating room will be maintained at 68 to 75 degrees F [Fahrenheit] (AORN [Association of Operating Room Nurses] Guidelines for Perioperative Practices, 2019 Edition) ...
Procedure:
Temperature and humidity will be monitored daily and logged in an Air Control Book by Operating Room Staff
A. If the temperature is above 75oF maintenance will be notified.
B. If the humidity is above 60%,[sic] Facilities Maintenance will be notified."

Review of the Centers for Disease Control (CDC) website revealed,
(https://www.cdc.gov/infection-control/media/pdfs
" ...Cool temperature standards (68°F-73°F [20°C-23°C]) usually are associated with operating rooms, clean workrooms, and endoscopy suites ...Relative humidity levels >60%, in addition to being perceived as uncomfortable, promote fungal growth."

Based on observation, interview, and policy review, the facility failed to ensure medication drawn up into a syringe to induce anesthesia was labeled. This failure had the potential to contribute to medication errors and increase the chance of an adverse outcome to patients. The survey census was 149.

Findings include:

Observation of the Certified Registered Nurse Anesthetist (CRNA) cart on 08/07/25 at 9:52 AM in the operating room, CRNA showed a drawer with medications drawn up in syringes with all but one, filled with a white fluid. CRNA confirmed it was Propofol, looked through the boxes with medication labels on the top of the cart and stated he had no labels for Propofol but "it's the only white one." CRNA proceeded to apply a yellow label and handwrote the drug name.

In an interview on 08/07/25 at 9:56 AM regarding the lack of a label on the syringe, Surgical Manager (SM) stated, "Anytime you take medication out of the original container it needs to be labeled.

Review of the facility policy titled, "Patient Safety in Anesthetizing Locations," effective date 05/02/19, revealed:
"Procedure:
VIII. Administration of drugs: ...
C. All medication on and off the sterile field must be labeled. This includes medications used by the anesthesia provider. . . ."