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Based on observation, interview and record review, the facility did not ensure that the Operating Room (O.R.) humidity (amount of moisture in the air) was maintained according to the hospital policy and procedure. This failure increased the risk of fire in the O.R. and injury to staff and surgical patients.

Findings:

During an observation on January 7, 2014, at 11:10 a.m., in O.R. 1, the humidity reading was observed to be 21%. During a concurrent interview, Staff 10 confirmed the observed humidity reading and stated he did not know which guidelines the facility followed for the appropriate O.R. temperature and humidity.

During an observation on January 7, 2014, at 11:30 a.m., outside of O.R. 1, the humidity reading was observed to be 21%. During a concurrent interview with Staff 4 and the O.R. manager, they both confirmed the humidity reading was 21%. The O.R. manager stated that the facility followed the AORN (Association of Perioperative Registered Nurses) national guidelines for appropriate O.R. temperature and humidity.

During a review of the facility "Temperature Log for the Surgery Unit" for January 2014, indicated the acceptable humidity range was "35-60%, Any deviation from the temperature ranges above must be corrected immediately. Attempt to bring temperature and/or humidity into acceptable range by adjusting the thermostat. If there is no thermostat, contact Environmental Services immediately. Recheck the temperature and/or humidity within one hour to see if temperatures are within the acceptable range. If not, notify the Surgical Services Manager. Please document all corrective actions taken, persons notified, and resolution." Further review of the Temperature Log indicated that for the date of January 7, 2014, the humidity for both O.R. 1 and O.R. 2 was documented as 21%. In the space indicated to document "Corrective Actions Taken," "humidifiers turned on in rooms 1 & 2" was indicated. In the space indicated to document "Action Results" the space was left blank. Further review of the Temperature Log indicated that the humidity in both O.R. 1 and O.R. 2 were documented as below the acceptable range of 35-60%, five out of the five days the O.R.'s were open in January 2014. A review of the December "Temperature Log for the Surgery Unit" indicated that the acceptable humidity range was 30-60%. The humidity in both O.R. 1 and O.R. 2 was documented as below the acceptable range of 30-60%, 14 out of 19 days the O.R.'s were open in December 2013. These findings were confirmed by the O.R. manager.

The facility policy and procedure titled, "Temperature and Humidity in the Operating Rooms" effective July 2010, indicated, "The humidity of the Operating Rooms shall be maintained between 30-60%... Surgical Services staff will contact the Plant Operations department if the temperature and/or humidity are out of range and cannot be controlled by actions made by the surgical services staff. The Plant Operations Department will ensure that the temperature is calibrated correctly."