HospitalInspections.org

Based on observations, document review, and staff interviews, it was determined that the facility failed to ensure a safe environment for the patients.

Findings include:

1. The facility failed to ensure the buildings air handling system was maintained and function sufficiently to ensure the safety and well-being of the patients to maintain facility temperatures in patient care areas in accordance with facility policy and FGI (Facility Guide Institute) guidelines. (Cross refer to Tag A 0724).

2. The facility failed to ensure temperature and humidity is monitored and maintained in Operating Rooms (ORs) and Sterile Storage areas, in accordance with facility policy and FGI (Facility Guide Institute) guidelines. (Cross refer to Tag A 0726).

Based on observations, staff interviews, review of facility documents and nationally recognized guidelines, it was determined that the facility failed to ensure the buildings air- handling system is maintained and functioning sufficiently to ensure the safety and well-being of the patients to maintain facility temperatures in patient care areas in accordance with facility policy and FGI (Facility Guidelines Institute) guidelines.

Findings include:

Reference: Facility policy titled "Utility Management Plan" Effective Date: February 2018, states, "... The facilities Department continuously monitors areas requiring pressure relationships or specific flow rates. ... Rates and locations are based upon community profile and recommendations from industry regulators such as AIA, FGI sic, ANSI, ...ASHRAE."

Reference: Facility policy titled "Temperature and Humidity Policy" Revised: May 2022, states, "...III. Procedure A. Temperature/Humidity Ranges: Area Patient Rooms ...Temperature 70-75 F...Humidity ... Max 60%..."

Reference: Guidelines for Design and Construction of Hospitals The Facility Guidelines Institute (FGI), 2018 edition, Table 7.1 page 9-11 states, "2.1-8.2 Heating, Ventilation, and Air-Conditioning (HVAC) Systems are defined as Part 3 (ANSI/ASHRAE/ASHE Standard 170: Ventilation of Health Care Facilities). ... Table 7.1 Design Parameters-Hospital Spaces,... Critical and Intensive Care ... 70-75 degrees Fahrenheit (F) ... Patient Room ... 70-75 degrees Fahrenheit ... Medication Room ... 70-75 degrees Fahrenheit ..."

Upon interview on 7/26/22 at 10:20 AM, Staff #1 stated that portable air conditioners were installed in the corridors throughout the hospital because the hospital air handlers could not maintain appropriate room temperatures. Staff #3 stated that a specific part needed to repair the hospital air handlers had been backordered by the manufacturer. Upon request, Staff #1 and Staff #3 were not able to provide written evidence that the backordered parts or alternative replacements had been ordered at the time of the survey.

On 7/26/22, a tour of the patient care areas were conducted in the presence of Staff #1 and Staff #4. Staff #4 took the room temperatures in the following areas and the following was identified:

At 10:23 AM, the thermostat read 82 degrees Fahrenheit in the Emergency Department (ED). Upon interview, Staff #6 stated that there was no temperature monitoring in the ED. The temperature readings were out of range in the following patient occupied areas in the ED:

At 2:17 PM, the temperature reading in the ED Main hallway was between 79 to 80 degrees Fahrenheit.
At 2:19 PM, the temperature reading in Room 13 was 78 to 79 degrees Fahrenheit
At 2:19 PM, the temperature reading in Room 14 was 77 degrees Fahrenheit.
At 2:20 PM, the temperature reading at the Nursing Station was between 81 to 83 degrees Fahrenheit.
At 2:21 PM, the temperature reading in the holding room H1 was 82.9 degrees Fahrenheit.
At 2:21 PM, the temperature reading in the holding room H2 was 92.1 degrees Fahrenheit. Staff #6 stated that this room was not being.
At 2:22 PM, the temperature reading in ED Bay 3 was 81 degrees Fahrenheit.
At 2:23 PM, the temperature reading in ED Bay 2 was 80.5 degrees Fahrenheit.

On 7/26/22, the temperature reading in the hallway by the elevator on the second floor was 83.6 degrees Fahrenheit. The temperature readings were out of range in the following areas, in patient occupied rooms on the 2nd floor:
Room 254: 81 degrees Fahrenheit
Room 257: 78 degrees Fahrenheit
Room 258: 78 degrees Fahrenheit
Room 261: 79 degrees Fahrenheit
Room 263: 79 degrees Fahrenheit
Room 269: 80 degrees Fahrenheit

On 7/26/22, the temperature readings were out of range in the following areas, in patient occupied rooms on the 5th floor (5 West step down):
Room 550: 81 degrees Fahrenheit
Room 558: 80.9 degrees Fahrenheit
Room 581: 80.9 degrees Fahrenheit
Room 557: 81 degrees Fahrenheit
Room 556: 78.1 degrees Fahrenheit
Room 582: 81.3 degrees Fahrenheit
Room 555: 79.2 degrees Fahrenheit
Room 583: 79 degrees Fahrenheit
Room 560: 79 degrees Fahrenheit
Room 561: 78.7 degrees Fahrenheit
Room 563: 83.7 degrees Fahrenheit
Room 564: 81 degrees Fahrenheit
Room 565: 80.5 degrees Fahrenheit
Room 566: 82.3 degrees Fahrenheit
Room 569: 81.3 degrees Fahrenheit

On 7/26/22, the temperature readings were out of range in the following areas, in patient occupied rooms on the 5th floor ICU (Intensive Care Unit):
Room 500: 76 degrees Fahrenheit
Room 524: 77.9 degrees Fahrenheit
Room 526: 77.5 degrees Fahrenheit

On 7/27/22, a tour of the occupied patient care areas were conducted in the presence of Staff #1, Staff #3, and Staff #4 from 10:36 AM to 12:00 PM. Staff #4 took the room temperatures and the following was identified:

On 7/27/22, the temperature readings were out of range in the following areas, in patient occupied areas in the Emergency Department:
Room ED 14: 77 degrees Fahrenheit
Room ED Xray: 77 degrees Fahrenheit
ED Patient Bays 2 and 3: 80 degrees Fahrenheit
ED GYN Room: 84 degrees Fahrenheit

On 7/27/22, the temperature readings were out of range in the following areas, in patient occupied rooms on the Medical/Surgical Unit 2 West:
Room 252: 76 degrees Fahrenheit
Room 255: 76 degrees Fahrenheit
Room 257: 77 degrees Fahrenheit
Room 260: 77 degrees Fahrenheit
Room 261: 76 degrees Fahrenheit
Room 262: 76 degrees Fahrenheit
Room 269: 78 degrees Fahrenheit

On 7/27/22, the temperature readings were out of range in the following areas, in patient occupied rooms on the 5th floor ICU:
Room 500 Bed 06: 76 to 77 degrees Fahrenheit
Room 500 526: 76-77 degrees Fahrenheit

On 7/27/22, the temperature readings were out of range in the following areas, in patient occupied rooms on the fifth floor step down 5 West:
Room 550: 77 to 79 degrees Fahrenheit
Room 555: 76 degrees Fahrenheit
Room 556: 78-79 degrees Fahrenheit
Room 557: 77-78 degrees Fahrenheit
Room 558: 77 degrees Fahrenheit
Room 562: 78 degrees Fahrenheit
Room 564: 78 degrees Fahrenheit
Room 565: 78 degrees Fahrenheit
Room 566: 77 degrees Fahrenheit
Room 569: 77 to 78 degrees Fahrenheit
Room 581: 78 to 79 degrees Fahrenheit
Room 582: 78 to 79 degrees Fahrenheit
Room 583: 77 to 78 degrees Fahrenheit

The above findings were confirmed by Staff #1 and Staff #4.

Based on observations, staff interviews, review of facility documents and nationally recognized guidelines, it was determined that the facility failed to ensure that temperature and humidity is monitored and maintained in the Operating Rooms and areas that sterile supplies are stored, in accordance with facility policy and FGI (Facility Guidelines Institute) guidelines.

Findings include:

Reference: Facility policy titled "Temperature and Humidity Policy" Revised: May 2022, states, "...III. Procedure A. Temperature/Humidity Ranges: Area Operating Room...Temperature 68-75 F...Humidity 20-60%..."

Reference: Guidelines For Design And Construction Of Hospitals The Facility Guidelines Institute (FGI) 2018 edition; Table 7.1 states, "... Design Parameters - Hospital Spaces (continued) Function of Space ...Operating Room [OR]...Pressure Relationship to Adjacent areas ... Positive... Minimum Total ach (air exchanges) ...20...Design Relative Humidity (k), %...20-60...Design Temperature (I), °F/°C...68-75/20-24..."

On 7/26/22 at 11:05 AM, a tour of the OR Suite was conducted in the presence of Staff #1 and Staff #4, and Staff #8. At 11:07 AM, in Operating Room 1, the temperature was 66.4 degrees Fahrenheit, which was not in accordance with facility policy and FGI guidelines. At 11:15 AM, a request was made to review the temperature and humidity logs for the month of July 2022 for all of the Operating Rooms (1, 2, 3, and 4). The logs indicated that the normal temperature range is 68 degrees Fahrenheit to 75 degrees Fahrenheit and the normal humidity range is 20 to 60 percent. The temperature and humidity were out of range on the following dates:

In OR 2:
7/6/22: 65.8 degrees Fahrenheit
7/7/22: 61.5 degrees Fahrenheit
7/8/22: 63.1 degrees Fahrenheit
7/11/22: 62.6 degrees Fahrenheit
7/12/22: 65 degrees Fahrenheit
7/13/22: 64 degrees Fahrenheit
7/14/22: 64 degrees Fahrenheit
7/15/22: 67 degrees Fahrenheit
7/20/22: 63 percent Humidity
7/21/22: 62 percent Humidity
7/22/22: 67 percent Humidity; 65.1 degrees Fahrenheit
7/24/22: 69 percent Humidity; 66.3 degrees Fahrenheit
7/25/22: 78 percent Humidity; 64.2 degrees Fahrenheit
7/26/22: 64 percent Humidity ; 63 degrees Fahrenheit
7/27/22: 61.2 degrees Fahrenheit

In OR 3:
7/1/22: 56.7 degrees Fahrenheit
7/7/22: 57.6 degrees Fahrenheit
7/8/22: 64 percent Humidity
7/11/22: 60.6 percent Humidity
7/12/22: 62.3 percent Humidity
7/13/22: 63 percent Humidity; 61 degrees Fahrenheit
7/14/22: 61.5 percent Humidity
7/15/22: 66 percent Humidity; 63.9 degrees Fahrenheit
7/19/22: 68 percent Humidity
7/22/22: 72 percent Humidity; 62.2 degrees Fahrenheit
7/24/22: 80 percent Humidity; 61.7 degrees Fahrenheit
7/25/22: 86 percent Humidity; 61 degrees Fahrenheit
7/26/22: 68 percent Humidity ; 60.3 degrees Fahrenheit

In OR 4:
7/1/22: 76 degrees Fahrenheit
7/13/22: 62 percent Humidity
7/15/22: 66 degrees Fahrenheit
7/20/22: 61 percent Humidity
7/21/22: 64 percent Humidity
7/22/22: 64 percent Humidity
7/24/22: 67 degrees Fahrenheit
7/25/22: 63 degrees Fahrenheit
7/26/22: 65.1 degrees Fahrenheit

Upon interview, Staff #4 stated that the facilities department for the boiler room had been informed. However, upon request, Staff #1 and Staff #4 were not able to provide evidence of performing corrective actions, at the time of survey. The above findings were confirmed by Staff #1 and Staff #4.

On 7/26/22 at 10:10 AM, in the presence of Staff #1, Staff #4, and Staff #6, sterile supplies were stored in the Emergency Department Sterile storage room. The temperature reading in the ED sterile storage room at 10:10 AM was 79 degrees Fahrenheit and 65 percent humidity. Upon interview, Staff #6 stated that the temperature and humidity was not monitored in this storage room and confirmed the above findings.

On 7/26/22 at 11:30 AM, in the presence of Staff #1, Staff #4, and Staff #10, sterile supplies were stored in the 2nd floor Clean Utility Room. Upon interview, Staff #4 confirmed that the temperature and humidity was not monitored in this storage area and confirmed the above finding.

On 7/26/22 at 12:02 PM, in the presence of Staff #1, Staff #4, and Staff #10, sterile supplies were stored in the 5th floor Clean Utility Room. The temperature reading was 88 degrees Fahrenheit and 37.7 percent humidity. Upon interview, Staff #4 confirmed that the temperature and humidity was not monitored in this storage area and confirmed the above finding.

The above findings were confirmed by Staff #1 and Staff #4.