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Based on observation, interview and record review, the facility failed, to protect and promote each patients' rights for two of 36 sampled patients (Patients 1 and 2) by:

1. Failing to ensure that the patients were cared for in a safe environment, free from all forms of abuse for two of 36 sampled patients (Patients 1 and 2) (A145), and

2. Failing to ensure that when possible sexual abuse was suspected the chain of command was followed for two of 36 sampled patients (Patients 1 and 2) (A145).

The cumulative effects of these systemic problems resulted in failure to ensure care was provided in a manner that protected the rights of each patient and kept patients free from abuse.

Based on interview and record review, the facility failed to ensure that patients were free from sexual abuse for two of 36 sampled patients (Patients 1 and 2), and failed to protect all other patients from potential abuse by allowing the suspected abusers (RN 3 and RN 6) to continue to have patient contact.

For Patient 1, the facility failed to protect the patient from alleged inappropriate touching when RN 3 was observed touching Patient 1's inner thigh with a bare hand.

For Patient 2, the facility failed to protect the patient from alleged inappropriate sexual behavior when RN 6 pulled at Patient 2's underwear unnecessarily and against the patient's will.

These failed practices placed the all patients at risk for abuse and injury.

Findings:

1. On August 25, 2010, the record for Patient 1 was reviewed. Patient 1, a 56 year old female, was admitted to the intensive care unit (ICU) at RSMC on July 4, 2010, at 1:30 a.m., with diagnoses including multiple rib fractures, pneumothorax, scapular fracture, and clavicle fracture on the left side resulting from a fall from a horse.

On August 25, 2010, at 8:30 a.m., an interview was conducted with the Director, Regulatory Compliance (DRC). She stated on August 20, 2010, at 12:30 a.m., the ICU charge nurse for the shift, RN 3, was seen, by RN 4 and RN 5, in Patient 1's room rubbing her head, face, and arms with both of his hands. The lights were on in the room and the room curtain at the door was open. RN 3 was not assigned to care for Patient 1 that shift. At approximately 3:30 a.m., RN 4 heard the "tachy alarm" (an equipment alarm that sounds when the patient's heart rate exceeds the maximum limit) for Patient 1 and went to investigate. The DRC stated, RN 4 saw RN 3 touching and moving his had back and forth on the inner, upper thigh of Patient 1. RN 3 was not wearing gloves and this was "skin to skin" contact. The sheet covering Patient 1 was at her knees, the lights were off in the room and the curtain at the door was partially drawn. RN 4 said "(RN 3's name)," and he jumped back, looked startled, and pulled the sheet up. RN 3 then requested RN 4 to assist him in pulling Patient 1 up in bed, but RN 4 stated the patient was already up in the bed. The House Supervisor (HS) 1 was notified of the event by RN 4 and RN 5, on August 20, 2010, at approximately 4 a.m. The HS advised RN 5 to speak with RN 3. The DRC stated, RN 5 spoke with RN 3 and all he said was "I am sorry, I am sorry." RN 3 did not leave the ICU, and continued as the ICU charge nurse for the remainder of the shift.

On August 25, 2010, at 10:15 a.m., an interview was conducted with Patient 1. She was unable to remember any male nurses, and stated, "One day goes into the next. I cannot remember. There are so many drugs involved."

The personnel file for RN 3 was reviewed on August 25, 2010, at 11:20 a.m., and indicated RN 3 was hired on July 21, 2008. Documentation in the personnel file for RN 3 indicated a prior incident of alleged possible inappropriate touching had occurred on April 24, 2009, and October 29, 2009, involving another female patient.

An "Employee Notification Performance MManagement Report" dated November 4, 2009, indicated RN 3 was placed on investigatory suspension on October 30, 2009, for Patient 12's complaint of inappropriate touching behavior while RN 3 was caring for her on April 24, 2009, and October 29, 2009. Patient 12 reported on October 30, 2009, that on April 24, 2009, while RN 3 was moving her right arm around he placed her hand in his groin, and RN 3 did this several times. In addition, during a subsequent hospitalization, on October 29, 2009, RN 3 seemed to press up against her and she felt slightly uncomfortable during a bath.

2. On August 25, 2010, the record for Patient 2 was reviewed. Patient 2, a 25 year old female, was admitted to medical/surgical services, at IVMC, on August 20, 2010, with diagnoses including acute cholecystitis (inflammation of the gallbladder) and recent postpartum state.

On August 25, 2010, at 2:05 p.m., an interview was conducted with Charge RN 1. She stated on August 22, 2010, at approximately 5:45 p.m., she received a telephone call from Patient 2's family member. The family member stated Patient 2 had told him that on the night shift for Saturday (August 21, 2010) to Sunday morning, RN 6's hand grazed Patient 2's left breast while RN 6 was checking her bandage but the bandage was on Patient 2's right side. Charge RN 1 stated the family member told her, RN 6 asked Patient 2 if she was on her "menses" because he noticed blood on the bed sheets. Patient 2 told RN 6 she was not menstruating, and the blood was from her intravenous catheter (IV), but RN 6 lifted her gown anyway to check for blood. The family member then stated, Patient 2 got up to go to the bathroom and RN 6 followed her. RN 6 kept insisting he needed to look in Patient 2's underwear for blood, and was trying to pull the waistband of her underwear away from her body. Patient 2 told RN 6 to "stop," but RN 6 continued until he pulled the front of her underwear open and looked at her vagina. Charge RN 1 stated she spoke with Patient 2 and she confirmed what the family member had said. Patient 2 also stated, "He made me feel uncomfortable."

On August 25, 2010, at 2:55 p.m., in a subsequent interview with Charge RN 1. She stated she e-mailed her immediate supervisor (CM 1), but did not verbally tell anyone of the reported allegation. In addition, she stated she did not document the conversation with the family member and/or Patient 2 in the record, did not notify the physician, and did not notify the house supervisor. Charge RN 1 stated when she made the patient care assignments for the next day, Sunday (August 22, 2010) evening to Monday morning, she did not assign RN 6 to Patient 2, and RN 6 worked the entire 12 hour shift on the unit.

The facility policy and procedure titled "Customer Complaint/Grievance" dated July 27, 2010, was reviewed on September 15, 2010, and indicated "... Grievance - Accusations of abuse, neglect or patient harm. ... Situations that may endanger the patient, such as neglect or abuse shall be reviewed immediately. The employee who has first knowledge will notify their Manager or the House Supervisor. The Manager or House Supervisor will notify the Chief Nursing Officer. ..."

The facility policy and procedure titled "Occurrence Notification System" with a revised date of June 2007, was reviewed on September 15, 2010, and indicated "... To improve patient care by providing appropriate immediate intervention on behalf of the patient and develop mechanisms to prevent future occurrences. ... Serious Occurrences - Sexual/criminal assault. ... The occurrence, exactly as noted, must be recorded in the medical record. ... The employee discovering the potentially harmful situation is to take appropriate steps to prevent harm to persons in the area, utilizing the chain of command as necessary. ... Record the date and time the physician was called and the response. ...

The facility policy and procedure titled "Professional Relationships With Patients" with a revised date of April 2003, was reviewed on September 15, 2010, and indicated "To provide management with appropriate guidelines to ensure that a professional relationship between employees and patients is maintained at all times. ... Employees - Report any unprofessional contact with or by a patient and/or family member to the employee's supervisor immediately. ... Supervisor - Promptly report any instances of improper or unprofessional employee conduct toward patients or patients' family members to the Human Resources Department. ..."

Based on observation, interview and record review, the facility failed to maintain the operating room temperature and humidity within the range specified by its own worksheets, which was also the standard of care. This failed practice placed the patients and staff in the OR at risk for fire, infection and discomfort.

Findings:

On August 25, 2010, at 3:45 p.m., a tour of surgical services at IVMC, was conducted with the Interim Director of Surgical Services (DSS).

The DSS stated, the facility was experiencing an external weather condition which caused a shift to emergency power at 2:03 p.m., and the operating rooms were currently out of compliance for the temperature and humidity in each room. In addition, she stated the surgical cases in rooms four and five would be completed, but no other cases would be started until the temperature and humidity range, in the operating room, were in compliance or a physician declared the surgical case was an emergency.

On August 25, 2010, at 4:30 p.m., a review of "Temperature / Humidity Log" indicated, "Acceptable temperature range 68? to 73? (action required if <68? or >73?). Acceptable humidity range 35% to 60% (action required if <35% or >60%)." High humidity and high temperature increases the risk of bacterial and fungal growth in areas where surgical procedures were performed and sterile supplies were maintained.

On September 9, 2010, at 11:50 a.m., an interview was conducted with the DSS. She stated, all of the operating rooms had obtained an acceptable temperature and humidity range by 7:35 p.m., on August 25, 2010.

On September 9, 2010, at 11:50 a.m., a review of the "Temperature / Humidity Log" for August 25, and 26, 2010, at IVMC indicated, on August 26, 2010, at 12:15 p.m., in operating room number five, the temperature reading was "61.8" and the humidity reading was "68.7."

On September 9, 2010, at 1:15 p.m., an interview was conducted with RN 1. She stated she probably reversed the temperature and humidity readings she had documented for operating room five on August 26, 2010, at 12:15 p.m., and the actual temperature was 68.7? and the humidity was 61.8%. In addition, she stated the humidity was out of the acceptable range. RN 1 stated, the physician did not say the case was an emergency, she did not document in the record the operating room was not within the acceptable humidity range, and she did not notify plant operations.

On September 9, 2010, at 1:30 p.m., an interview was conducted with the Lead OR RN. She stated a surgical case must be cancelled if the temperature and/or humidity in the operating room was not within the acceptable range.

During a subsequent interview with the DSS, on September 9, 2010, at 1 p.m., she reviewed the "Temperature / Humidity Log" dated August 26, 2010, at 12:15 p.m., for operating room five, and confirmed the nurse probably reversed the temperature and humidity readings. In addition, she stated the humidity in the room was not within the acceptable range and the surgical case should have been cancelled until the humidity was within the acceptable range of 35% to 60%.

On September 21, 2010, at 10:45 a.m., the "Temperature / Humidity Log" for IVMC, for July, August, and September 2010, were reviewed. The "Temperature / Humidity Log" indicated:

a. On July 15, 2010, at 3 p.m., in OR five, the humidity was 68%, the surgical case for Patient 9 was initiated, and it was "N/A (not applicable)" for a resolution to the humidity not being within the acceptable range.

b. On July 20, 2010, at 10:15 a.m., in OR one, the temperature was 74.6?F, the surgical case for Patient 8 was initiated, and it was "N/A (not applicable)" for a resolution to the temperature not being within the acceptable range.

c. On August 17, 2010, at 5:56 p.m., in OR five, the humidity was 60.7%, the surgical case for Patient 11 was initiated, and the space for a resolution to the humidity not being within the acceptable range was blank.

On September 20, 2010, at 3 p.m., an interview was conducted with the PO Manager. He stated if an OR was not within the acceptable range for temperature and/or humidity, a work order was initiated by surgical services personnel and a telephone call was made to plant operations. In addition, he stated the plant operations staff initialed the "Temperature / Humidity Log" to include actions taken, and resolution date and time.

On September 21, 2010, at 11 a.m., a subsequent interview was conducted with the PO Manager. He stated plant operations had not been notified and work orders had not been initiated on July 15, 2010, at 3 p.m., for OR five; on July 20, 2010, at 10:15 a.m., for OR one; or on August 17, 2010, at 5:56 p.m., for OR five.

On September 21, 2010, at 1:05 p.m., an interview was conducted with the DSS, and she reviewed the "Temperature / Humidity Log" and records for Patients 8, 9, and 11. She stated the surgical cases were non-emergent, the nurses had not documented a concern with the temperature or humidity, and there was no documentation by the nurses of the recognition that the temperature or humidity was outside of the acceptable range.

The facility policy and procedure titled "Temperature / Humidity Monitoring, Peri-Op" with a revised date of May 2010, was reviewed on August 25, 2010. The policy and procedure indicated, "To monitor the temperature and humidity levels in the perioperative setting as both are associated with the principals of fire and safety and infection control in the surgical setting. ... Perioperative Temperature Range: 68?F - 73?F. Perioperative Humidity Range: 35% - 60%. ... A temperature or humidity reading that is out-of-range is recorded on the log. The staff member shall immediately contact Plant Operations and initiate a work order. ... Operating Room: A surgical case will not begin until the temperature and/or humidity in the operating room is in the proper range. ..."

From "Perioperative Standards and Recommended Practices 2010 Edition", Section III - Recommended Practices for Perioperative Nursing
Patient and Worker Safety:
V.b. Relative humidity should be maintained between 30% and 60% within the perioperative suite ...
V.c.1. Temperature should be maintained between 68? F to 73? F (20? C to 23? C) within the operating room suite ... American Institute of Architects Academy of Architecture for Health (AIAAAH) recommends a humidity range of 30% to 60% for the OR.

Based on observation, interview, and record review, the facility failed to provide surgical services in accordance with acceptable standards practices by:

1. Failing to ensure the facility's policies and procedures for cleaning and sterilization of surgical equipmentTissue from a previous surgical case falling into the open surgical cavity of Patient 3 (A 951).

2. Failing to ensure documentation on the nursing intraoperative record of the occurrence when tissue from a previous surgical case fell into the open surgical cavity of Patient 3 (A 951).

3. Failing to ensure the rapid cycle sterilizers were being tested on days when surgical cases were being performed in the operating room (A 951).

4. Failing to ensure the temperature and humidity monitoring of the operating rooms was implemented and followed and that surgical cases being performed in operating rooms that were not in compliance with humidity and/or temperature ranges (A 726 and A 951).

The cumulative effect of these systemic problems resulted in the facility's inability to provide safe surgical care in accordance with acceptable standards of practice.

Based on observation, interview, and record review, the facility failed to ensure the facility's policies and procedures were implemented and followed for surgical services.

1. For Patient 3, the facility failed to ensure proper cleaning and sterilization of surgical equipment,which resulted in tissue from a previous surgical case falling into the open surgical cavity of Patient 3, and failed to document the occurence in the patient's medical record.

2. The rapid cycle sterilizers were not tested on days with scheduled surgical cases. Resulting in the potential for items that were sterilized in the rapd cycle sterilizer, not being adequately sterilized.

3. Failed to ensure that when the temperature and humidity levels were not in the appropriate range, corrective action was taken and no non-emergent surgical cases were being performed in operating rooms that were not in compliance with humidity and/or temperature ranges.

These failed practices can potentially lead to an increased risk of infection, injury, or death to the patient undergoing a surgical procedure.

Findings:

1. On September 15, 2010, the record for Patient 3 was reviewed. Patient 3 was admitted to the hospital on August 26, 2010, for surgical repair of cervical spondylosis (age-related wear and tear on the disks of the neck) at "C3 - 4, C4 - 5, C5 - 6, and C6 - 7."

The "Intraoperative Record" dated August 26, 2010, indicated Patient 3 entered the operating room at 12:45 p.m., and left the operating room at 4:15 p.m.

The physician's "Operative Report" dated September 7, 2010, indicated "... A second distractor pin was being placed into the anterior portion of the vertebral body at C6 when a foreign body was noted to fall into the field. This was removed and was found to be consistent with a desiccated tissue not from this patient. The tissue was sent immediately to the pathology lab. The distractor pins were removed. The field was irrigated with copious quantities of sterile irrigation and the distractor handling pin that had been used was removed from the surgical field. ..."

On September 15, 2010, at 10:40 a.m., an interview was conducted with the Interim Director of Surgical Services (DSS). She stated the handle of the Shadowline retractor used by the surgeon on August 26, 2010, during the surgical case for Patient 3, contained an imprint of the tissue that fell into the open surgical cavity. In addition, she stated neither the scrub technicians nor the circulating nurse saved the trays indicator tape (changes color if the tray has been sterilized) or the indicator inside the wrapping, which would have indicated that the Shadowline retractor had been sterilized and which staff member had wrapped the retractor for sterilization. Also, the DSS stated the last time the Shadowline retractor had been sterilized was August 18, 2010, at 2:33 p.m., but she could not tell which sterile processing technician had cleaned, processed, wrapped or sterilized the retractor.

On September 15, 2010, at 11:45 a.m., a tour of sterile processing was conducted with the DSS. The "Load List & Process Documentation System" dated August 18, 26, and 31, 2010, were reviewed. The documentation system indicated the Shadowline retractor was processed on these days, but there was no indication of who had processed the retractor.

The "Pathology Microscopic Examination" dated August 31, 2010, indicated "Foreign substance from retractor regarding the case of (Patient 3) on 8/26/10 at Inland Valley Medical Center OR. ... 27 x 8 x less than 1 mm fragment of tan-red paparacious tissue. ... Diagnosis: FOREIGN OBJECT: - VIABLE FIRBOADIPOSE TISSUE - FOREIGN MATERIAL FIBERS."

On September 21, 2010, at 2:30 p.m., an interview was conducted with the Pathologist. He stated the tissue "looked healthy" and like it had not been run through the sterilizer. In addition, they would have expected it to be "non-viable." The Pathologists recommended the hospital run a tissue sample through the sterilizer to see what the tissue would look like, and to the best of their knowledge, if viable, the tissue could infect another patient with organisms.

The facility policy and procedure titled "Central Service: Cleaning & Sterilizing Equipment & Supplies" with a revised date of November 2009, was reviewed on September 15, 2010, and indicated "... Instruments not grossly soiled will be individually unlocked, opened, and inspected for dirt, soil, bioburden, or any foreign material prior to being placed in the ultrasonic and or washer-disinfector. ... Instrument sets that are wrapped are sealed using indicator tape, which shows whether or not the item has been exposed to the sterilization process. Label the item on the tape with the correct description of the instrument or tray and initials of person preparing the package, using indelible marker. ... The proper indicator is placed in each package or tray prior to sterilization. ... Assembling Trays and Sets ... Instruments should be inspected for cleanliness, proper functioning and alignments ..."

The "Intraoperative Record" dated August 26, 2010, indicated Patient 3 entered the operating room at 12:45 p.m., and left the operating room at 4:15 p.m. The record did not indicate a foreign body fell into the field, what steps were taken after this event, medications used in the irrigation process, and who was notified of the event occurring in the operating room.

During an interview with the DSS, on September 15, 2010, at 11 a.m., she reviewed the record and was unable to find documentation of the event when the foreign body fell into the field, interventions that were performed, medications used in the irrigation process, or to whom the nurse reported the event. She further stated the nurse should have documented the incident in the intraoperative record to include what occurred, what actions were taken, the outcome, and who the nurse notified when she followed her chain of command.

The facility policy and procedure titled "Occurrence Notification System" with a revised date of June 2007, was reviewed on September 15, 2010, and indicated "... The completed report with investigation and action taken will be routed to the Risk Management Director with 24 hours of the occurrence. ... Details of the event should be appropriately documented in the patient's medical record. ..."

2. On September 20, 2010, at 9:20 a.m., a tour of surgical services at RSMC was conducted with the OR Charge Nurse.

The rapid cycle sterilizer, used for the steam sterilization of unwrapped surgical instruments and other medical devices, was located between ORs one and two.

There was no "Daily Rapid Cycle Sterilization Log" for September 4 and 5, 2010. The OR Charge Nurse stated, if no surgical cases had been performed on September 4 and 5, 2010, the rapid cycle sterilizer was not required to have a testing biological load.

The RSMC log of surgical procedures was reviewed on September 20, 2010, at 11 a.m. The log indicated three surgical cases were performed on September 4, 2010, and two surgical cases were performed on September 5, 2010.

On September 21, 2010, at 9 a.m., a tour of surgical services at IVMC was conducted with the DSS and OR Manager.

A rapid cycle sterilizer was located between ORs one and two, and between ORs four and five. Th DSS stated, the rapid cycle sterilizers had a biological load testing every morning with the exception that the rapid cycle sterilizer between ORs four and five was not tested on weekends because ORs four and five were not utilized on the weekends.

On September 21, 2010, at 9:15 a.m., the "Rapid Biological Indicator, Process Monitor Documentation System" log for September 2010, was reviewed and indicated biological testing was not done, for the rapid cycle sterilizer between ORs one and two, on September 5, 11, 12, 18, and 19, 2010.

On September 21, 2010, at 9:20 a.m., the IVMC "OR Schedule" was reviewed. Eight surgical cases were performed on September 5 and 11, 2010; seven surgical cases were performed on September 12 and 18, 2010; and four surgical cases were performed on September 19, 2010.

On September 21, 2010, at 9:45 a.m., a subsequent interview was conducted with the DSS. She stated the rapid cycle sterilizer should have been tested if surgical cases were performed. In addition, she stated surgical services staff were trained on how to "test" the rapid cycle sterilizer for those occasions when sterile processing personnel were not working.

The facility policy and procedure titled "Sterilization - Steam Using Unwrapped Method (Rapid Cycle Sterilizer)," with a revised date of December 2009, was reviewed on September 21, 2010, and indicated "... A testing biological load will be run every morning before the start of the first case of the day and with all implant loads. ..."

3. On August 25, 2010, at 3:45 p.m., a tour of surgical services, at IVMC, was conducted with the Interim Director of Surgical Services (DSS).

The DSS stated, the facility was experiencing an external weather condition which caused a shift to emergency power at 2:03 p.m., and the operating rooms were currently out of compliance for the temperature and humidity in each room. In addition, she stated the surgical cases in rooms four and five would be completed, but no other cases would be started until the temperature and humidity range, in the operating room, were in compliance or a physician declared the surgical case was an emergency.

On August 25, 2010, at 4:30 p.m., a review of "Temperature / Humidity Log" indicated, "Acceptable temperature range 68? to 73? (action required if <68? or >73?). Acceptable humidity range 35% to 60% (action required if <35% or >60%)." High humidity and high temperature increases the risk of bacterial and fungal growth in areas where surgical procedures were performed and sterile supplies were maintained.

On September 9, 2010, at 11:50 a.m., an interview was conducted with the DSS. She stated, all of the operating rooms had obtained an acceptable temperature and humidity range by 7:35 p.m., on August 25, 2010.

On September 9, 2010, at 11:50 a.m., a review of the "Temperature / Humidity Log" for August 25, and 26, 2010, at IVMC indicated, on August 26, 2010, at 12:15 p.m., in operating room number five, the temperature reading was "61.8" and the humidity reading was "68.7."

On September 9, 2010, at 1:15 p.m., an interview was conducted with RN 1. She stated she probably reversed the temperature and humidity readings she had documented for operating room five on August 26, 2010, at 12:15 p.m., and the actual temperature was 68.7? and the humidity was 61.8%. In addition, she stated the humidity was out of the acceptable range. RN 1 stated, the physician did not say the case was an emergency, she did not document in the record the operating room was not within the acceptable humidity range, and she did not notify plant operations.

On September 9, 2010, at 1:30 p.m., an interview was conducted with the Lead OR RN. She stated a surgical case must be cancelled if the temperature and/or humidity in the operating room was not within the acceptable range.

During a subsequent interview with the DSS, on September 9, 2010, at 1 p.m., she reviewed the "Temperature / Humidity Log" dated August 26, 2010, at 12:15 p.m., for operating room five, and confirmed the nurse probably reversed the temperature and humidity readings. In addition, she stated the humidity in the room was not within the acceptable range and the surgical case should have been cancelled until the humidity was within the acceptable range of 35% to 60%.

On September 21, 2010, at 10:45 a.m., the "Temperature / Humidity Log" for IVMC, for July, August, and September 2010, were reviewed. The "Temperature / Humidity Log" indicated:

a. On July 15, 2010, at 3 p.m., in OR five, the humidity was 68%, the surgical case for Patient 9 was initiated, and it was "N/A (not applicable)" for a resolution to the humidity not being within the acceptable range.

b. On July 20, 2010, at 10:15 a.m., in OR one, the temperature was 74.6?F, the surgical case for Patient 8 was initiated, and it was "N/A (not applicable)" for a resolution to the temperature not being within the acceptable range.

c. On August 17, 2010, at 5:56 p.m., in OR five, the humidity was 60.7%, the surgical case for Patient 11 was initiated, and the space for a resolution to the humidity not being within the acceptable range was blank.

On September 20, 2010, at 3 p.m., an interview was conducted with the PO Manager. He stated if an OR was not within the acceptable range for temperature and/or humidity, a work order was initiated by surgical services and a telephone call was made to plant operations. In addition, he stated the plant operations staff initialed the "Temperature / Humidity Log" to include actions taken and resolution date and time.

On September 21, 2010, at 11 a.m., a subsequent interview was conducted with the PO Manager. He stated plant operations had not been notified and work orders had not been initiated on July 15, 2010, at 3 p.m., for OR five; on July 20, 2010, at 10:15 a.m., for OR one; or on August 17, 2010, at 5:56 p.m., for OR five.

On September 21, 2010, at 1:05 p.m., an interview was conducted with the DSS, and she reviewed the "Temperature / Humidity Log" and records for Patients 8, 9, and 11. She stated the surgical cases were non-emergent, the nurses had not documented a concern with the temperature or humidity, and there was no documentation by the nurses of the recognition that the temperature or humidity was outside of the acceptable range.

The facility policy and procedure titled "Temperature / Humidity Monitoring, Peri-Op" with a revised date of May 2010, was reviewed on August 25, 2010. The policy and procedure indicated, "To monitor the temperature and humidity levels in the perioperative setting as both are associated with the principals of fire and safety and infection control in the surgical setting. ... Perioperative Temperature Range: 68?F - 73?F. Perioperative Humidity Range: 35% - 60%. ... A temperature or humidity reading that is out-of-range is recorded on the log. The staff member shall immediately contact Plant Operations and initiate a work order. ... Operating Room: A surgical case will not begin until the temperature and/or humidity in the operating room is in the proper range. ..."