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1. Based on observation, review of professional literature, review of Patient Care Event reports, review of electronic mail (e-mail) communication, review of Operating Room (OR) logs, policy and procedure review, review of humidity logs, and staff interview, the Critical Access Hospital (CAH) failed to perform surgical procedures in a safe manner by failing to maintain compliance with applicable regulations and guidelines governing surgical services, including standards and recommendations established by nationally recognized professional organizations, to monitor and ensure relative humidity (RH) levels in the surgical department did not exceed the recommended range of 60 percent for 3 of 3 months (May, June, and July 2013) reviewed. Due to the fact excessive humidity is conducive to microbial growth and compromises the integrity of wrapped sterile instruments and supplies, failure to monitor RH levels within the surgical department and ensure the RH did not exceed sixty percent placed patients at an increased risk of surgical site infection.

Findings include:

Review of the policy, "Infection Control Guidelines for Surgery and Recovery Room," occurred on July 24, 2013. This policy, revised September 2000, stated, "Policy: Prevention of indirect and direct transmission of infectious disease is imperative in the OR. . . ."

"Guidelines for Construction and Equipment of Hospital and Medical Facilities," 1992-93 edition, Chapter 7, Section 7.31, Subsection 7.31. D. Air Conditioning, Heating, and Ventilation Systems stated, ". . . 7.31.D.1. . . . All rooms and areas in the facility used for patient care shall have provisions for ventilation. . . . c. The ventilation systems shall be designed and balanced according to the requirements shown in Table 2 and in the applicable notes. . . . Table 2 . . . SURGERY . . . Operating/surgical, cystoscopic rooms . . . Relative humidity (%) [percent] . . . 50-60 . . . Table 2 Notes: 1. The ventilation rates in this table cover ventilation for comfort, as well as for asepsis . . . in areas of acute care hospitals that directly affect patient care . . . Refer to ASHRAE Standard . . ."

"Ventilation of Health Care Facilities", the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) publication of the ANSI (American National Standards Institute)/ASHRAE/American Society for Healthcare Engineering (ASHE) Standard 170-2008, dated 2008, pages 2, 6, and 7 stated, ". . . This standard provides . . . ventilation parameters. Without high-quality ventilation in health care facilities, patients, health care workers, and visitors can become infected through normal respiration of particles in the air. Poorly ventilated health care facilities are places where the likelihood of pathogenic particles occurring in the air is quite high. These air-transmitted pathogens can be found everywhere in poorly ventilated health care facilities . . . Because these organisms are found in higher concentrations in hospitals, additional care must be taken . . . 2. SCOPE: 2.1 The requirements in this standard apply to patient care areas and related support areas within health care facilities, including hospitals . . . 7. SPACE VENTILATION: The ventilation requirements of this standard are minimums that provide control of environmental comfort, asepsis . . . in health care facilities. . . . 7.1 General Requirements. The following general requirements shall apply for space ventilation: 1. Spaces shall be ventilated according to Table 7-1. . . . b. The ventilation rates in this table are intended to provide for . . . asepsis . . . in areas of a health care facility that directly affect patient care. . . . TABLE 7-1 Design Parameters . . . SURGERY . . . Classes B and C operating rooms . . . RH . . . % . . . 30-60 . . . Operating/surgical cystoscopic rooms . . . RH . . . % . . . 30-60 . . ."

An article from the Association of Perioperative Registered Nurses (AORN), updated 06/30/09, stated, ". . . The recommended humidity range in an operating room is between 30% to 60%. Both the temperature and humidity should be monitored and recorded daily using a log or electronic documentation of the heating, ventilation, and air conditioning (HVAC) system . . . The potential risk of microbial growth increases in areas where sterile supplies are stored when the humidity is too high. . . ."

A published addendum to ASHRAE's standard 170-2008, dated 2010, reduced the lower limit of the design humidity range in anesthetizing locations from 30% to 20% after an extensive review process. The ASHRAE review retained the previously established upper limit of the design humidity range of 60%, indicating this as an important element in reducing infections and preventing mold and mildew in anesthetizing locations.

- During an interview in the afternoon on 07/23/13, an administrative surgical staff member (#1) stated the CAH performed surgical procedures primarily during the day time hours Monday through Friday and provided on-call coverage after hours, on weekends, and holidays as needed. The staff member (#1) stated the department maintained and utilized six OR rooms; four rooms used primarily for general and regional anesthesia in addition to a "cystoscopy (cysto)" and "minor" room.

Review of the OR log for the past three months (May through July 2013) occurred on 07/23/13 and showed the CAH performed an average of six to 18 surgical procedures a day during the week, and two to six during the weekends, utilizing all six OR rooms.

Observation of OR #4 and the cysto and minor room in the afternoon on 07/23/13 lacked evidence of a method or manner to identify and/or monitor the RH of the rooms. An administrative surgical staff member (#1) stated the maintenance department measured RH levels throughout the hospital, but did not know how often this occurred or the results of the RH readings as the maintenance department did not communicate the information with him or the surgical department. The staff member (#1) stated he implemented a "log tag" device to monitor RH levels in all OR rooms in February 2013. Staff place the devices in a room to continuously monitor the temperature and humidity. A light on the device changes from green to red to alert staff if the readings are out of the recommended RH range of 20-60%. Staff can download data from the device on a computer to view the readings. The staff member (#1) identified OR #3, #1, and the central core as the rooms containing the log tags at the current time due to administration advising against the use of the log tag devices. He identified he had been using the devices to monitor RH since the hospital had no other system in place to do so (even though administration advised to monitor the RH once a month).

Review of the maintenance department's humidity logs for the surgical department for May, June, and July 2013 occurred on 07/24/13 and identified maintenance staff monitored the temperature and humidity in three areas; OR #2, Central Supply Room (C.S.R), and Sterile Hallway, once a month. The humidity levels during this time period ( 05/20/13, 06/26/13, and 07/17/13) remained below 60 percent. An interview with an administrative maintenance staff member (#4) on 07/24/13 at 3:00 p.m. identified maintenance staff measured the humidity in these three areas with a hand held device brought to the area by the staff member to obtain the reading.

During an interview in the afternoon on 07/23/13, an administrative surgical staff member (#1) stated with the implementation of the log tag devices collecting RH readings daily in each of the six OR's, data showed random increases in RH the past few months. He stated an event occurred approximately three weeks ago in which the RH in the OR rooms increased dramatically and confirmed RH readings of greater than 60% for a week. The staff member (#1) stated staff saved data from the log tag devices since implementation, but recently the data has been unretrievable. He provided a portion of retrievable log tag data, which upon review on 07/24/13, showed the following readings surrounding the event for July 2013:
*OR #1: RH greater than 60% on July 01-07 (ranges from 62 to 88.1%).
*OR #3: RH greater than 60% on July 01 and 02 (ranges from 62 to 68.4%), July 03 and 04 (ranges from 61 to 77%), and July 05 to 07(ranges from 61 to 88.7%).
*OR #2: RH greater than 60% on July 01 and 02 (ranges from 62 to 66.7%), July 03 (ranges from 62 to 75.8%), and July 04, 05, and 06 (ranges from 62 to 85.9%).
The staff member (#1) stated maintenance department staff monitored the RH daily with a manual device for about a week after the event, then stopped as the hospital felt the problem resolved and needed monitoring monthly as before.

An interview with an anesthesia staff member (#2) occurred on 07/24/13 at 11:00 a.m. The staff member (#2) stated the hospital had two power outages on July 5, 2013 which prompted a call to the nursing supervisor and stated the OR staff noticed a problem when the floors "never dried" from cleaning, became slippery, and the room felt "hot." The anesthesia staff member (#2) stated staff notified maintenance regarding the situation and later that evening, at 11:30 p.m., the OR staff convened for an emergency case and noticed the room was "very, very hot - everyone physically sweating." She stated the OR was "very humid" and "papers were curling" the next morning (Saturday, July 6, 2013) and stated the humidity levels the following day (Sunday, July 7, 2013) were very high. The staff member (#2) stated staff notified the Administrator on call and the CAH stopped all non-emergent surgeries. After the event, the staff member (#2) stated OR staff "purged supplies" to ensure sterility.

An interview with an OR staff member (#3) occurred on 07/24/13 at 12:20 p.m. The staff member (#3) stated staff placed "Log Tags" in the OR rooms, sterile hall, and the supply room to monitor temperature and humidity. The staff member stated the log tags are "always blinking red in the morning," indicating the temperature or humidity is out of range. The staff member stated that the "air was not moving a couple of week-ends ago" and when staff came in for an emergency C-section, the floors were "wet and slippery" during the surgery. The next day (Saturday, July 6, 2013), the staff completed "8 cases" in the OR. The staff member stated on Sunday, (July 7, 2013), "we pulled supplies" and stopped surgeries except emergencies because of the humidity and temperature.

- Review of Patient Care Event reports occurred on July 23-24, 2013 and identified the following:
*07/07/13 ". . . Event date and time: 07/05/13 [6:00 p.m.] . . . Description of the Event: Around 6 pm on 7-5-13, there were two electrical outages. Maintenance was notified to verify we were not on generator power before we proceeded with a surgical case. That was verified, so we proceeded in OR 2. During that case, the floors in the room became wet to the point of being difficult to stand on. OR 1 had damp floors at that time as well. We did not notice that there was a problem with the air conditioner at that time. Later that evening (approx 2230) [approximately 10:30 p.m.) we were called back to do a stat [immediate] [cesarean section] Room 3 was obviously hot and humid. Staff literally had sweat running down themselves. We were told that the air conditioner was down and there was not an estimated time of repair. After the case ended and we were cleaning and restocking, it seemed that there was cool air flow, indicating that the air conditioner was repaired. The following day, we did cases in room 4 and 3. It seemed like room 3 was cold, but clammy. Chart papers were actually to the point of curling. After that case, I attempted to contact [name of OR manager], regarding concern over the integrity of the OR . . . Immediate Actions Taken: Maintenance was contacted regarding the power outage Friday night. Attempt to contact [name of OR manager] Saturday morning regarding situation. Contact made with [name of OR manager] Saturday evening . . . Room: Not identified . . . Patient Name: Not identified . . . Comments: Slow ability to fix problem. . . . Comments: Concern discussed at daily check in. Issue with communication and house supervisor not being called . . . Initial Contributing Factors: Storm in area affecting electrical system."

* 07/08/13 ". . . Event date and time: 07/05/13 [4:51 p.m.] . . . Description of the Event: Following a short power outage in the hospital the air circulation/ventilation system in the Operating Rooms failed to perform to standard. The environment inside the OR's (sic) became excessively humid and warm to the point of causing the floors to become extremely slippery, paperwork had a "soggy" limp feel resulting in the edges of some sheets curling upward and walking across the floor left puddles of water in the footprints . . . Immediate Actions Taken: OR Manager notified of events . . . Patient Name: [Patient #22] . . . Room: OR #2 . . . Comments: Infection control to follow. . . . Initial Contributing Factors: Power outage creating adverse event in environmental control system which was not detected by the monitoring systems presently in place."

Hospital staff completed the same Patient Care Event report as above for the following surgeries: Patient #7 (event time:7:13 p.m. in OR #2) and Patient #6 (event time:10:45 p.m. in OR #3) on 07/05/13, Patient #23 (event time:7:07 a.m. in OR #4), Patient #8 (event time: 10:01 a.m. in OR #3), and Patient #21 (event time:12:23 p.m. in OR #2) on 07/06/13, and Patient #24 (event time: 9:34 a.m. in OR #4) and Patient #25 (event time: 4:22 p.m. in OR #4) on 07/07/13.

Review of the OR log confirmed surgical procedures performed on the dates specified in the above incident reports and showed the following:
*07/05/13 from 4:48 p.m. to 5:43 p.m. - Patient #22 underwent surgery for a K-wire fixation to the left first metatarsal.
*07/05/13 from 6:23 p.m. to 7:21 p.m. - Patient #7 underwent surgery for revision of a left long fingertip amputation.
*07/05/13 from 10:40 p.m. to 11:59 p.m. - Patient #6 underwent a c-section.
*07/06/13 from 7:05 a.m. to 8:00 a.m. - Patient #23 underwent a removal of a foreign body examination under anesthesia.
*07/06/13 from 10:01 a.m. to 11:37 a.m. - Patient #8 underwent a c-section.
*07/06/13 from 12:41 p.m. to 1:48 p.m. - Patient #21 underwent a closed reduction with application of external fixator left wrist surgery.
*07/07/13 from 9:34 a.m. to 10:40 a.m. - Patient #24 underwent an esophagogastroduodenoscopy (EGD) procedure.
*07/07/13 from 4:22 p.m. to 4:59 p.m. - Patient #25 underwent an EGD procedure.

During an interview on 07/24/13 at 2:00 p.m., an administrative maintenance staff member (#4) stated the hospital developed a plan to control the humidity and temperature in the OR in response to the event which occurred earlier in July and provided a memo outlining the plan. The memo, sent via e-mail to "Mercy Providers" on 07/08/13 at 2:23 p.m. from two administrative staff members (#4 and #8), stated, "Status of Humidity Issues in the OR's . . . At this point (1:30 pm - Monday) we are actively assessing the OR supply inventory to determine the affect of humidity exposure. We have the humidity issue resolved but we need to assess the OR supplies to make sure we have everything necessary for normal and trauma surgeries. We are equipped to perform C-sections. Some supplies will need to be removed and re-ordered. We will provide more information before the end of the business day (5pm). The humidity level is being monitored in the Inpatient OR's and we believe the issue has been resolved. The cause of the problems relates to several power outages that impacted the Chiller - a piece of equipment that provides chilled water. This chilled water is used for cooling and to remove humidity. Until further notice we intend to perform manual monitoring of humidity and temperature in the OR's every four hours (noon, 4pm, 8 pm, midnight, 4 am, 8am). This will allow us to assess the levels, make corrective actions if necessary and notify the appropriate managers if acceptable ranges have been exceeded. The temperature and humidity levels are closely related and we have seen the temperature set at 60 degrees in the OR's which drives up the relative humidity. We have also experienced extremely high natural humidity levels approaching 93% at 4:52 am this morning. To maintain appropriate humidity levels it will be helpful to set the temperatures to consistent values when not in use. We would recommend the following temperature settings: 68 Degrees when OR room is Not in Use, 65-68 Degrees when OR is being used - set to physician preference, 68-70 Degrees for Storeroom . . . "

The administrative maintenance staff member (#4) provided another e-mail sent from an anesthesiologist (MDA) to the certified registered nurse anesthetists (CRNA's) on 07/09/13 at 10:32 a.m. which stated, "The OR has maintained humidity within an acceptable range for 24 hours. We can schedule cases. However, the supplies needed for a specific case must be approved by the responsible OR nurse and surgical technician. The temperature in each OR should be set at 68-70 [degrees] after cases. If the surgeon requests a lower temp for the operative time, the thermostat may be turned down but returned to the above setting when ending the case. The OR 1-4 will be checked every four hours and documented for the rest of the week. If anything about the physical plant (heating, cooling, other problem) occurs please call me. . . . "

Review of the temperature and humidity readings monitored by the maintenance department during the week of July 8-12, 2013 occurred on 07/24/13 at 3:45 p.m. The log showed facility staff monitored the temperature and humidity levels in OR Rooms 1-4 and the Storage area approximately every four hours from 8:00 a.m. on July 08, to 4:00 p.m. on July 12. According to the log, the humidity levels during this time period remained below 60%.

During an interview on 07/24/13 at 2:30 p.m., an administrative maintenance staff member (#4) stated the CAH fixed the issue with the air conditioning system as soon as the problem occurred. The staff member (#4) stated after performing daily RH readings of the four OR rooms for four days with no RH readings greater than 60% after the event, staff felt they could monitor RH readings on a monthly basis as previously established.

During an interview on 07/24/13 at 3:30 p.m., an administrative staff member (#6) stated the high levels of humidity outdoors this season contributed to the humidity problems within the CAH and stated the maintenance department fixed the chiller system which controls the humidity after the event during the first week in July. He stated the air handling system would alert or alarm when the system detected high humidity levels. The staff member (#6) stated monthly checks of RH in the surgical department as sufficient.

CAH staff failed to provide evidence of the analysis and repair of the chiller system and whether the air handling system detected any problems at the time of the event.

During an interview on 07/24/13 at 3:50 p.m., an administrative nurse (#5) stated the CAH has not discussed the concerns with the increased RH levels in the OR from a "quality standpoint" and confirmed no corrective action or monitoring occurred other than monitoring the RH and temperature for four days following the event. The staff member (#5) stated CAH staff did not develop or implement a policy and procedure in relation to RH monitoring following the event.

- An interview occurred in the morning on 07/24/13 with an administrative surgical staff member (#1), an anesthesia staff member (#2), and an OR staff member (#3). All three staff members (#1, #2, and #3) reported issues with high humidity in the surgical department prior to the event the first week in July, stated staff submitted work orders to the maintenance department about the issues, and indicated the OR continued to have problems with humidity. A staff member (#2) stated several OR staff members had concerns with the air handling system in relation to the humidity and temperature of the OR and have asked the Administrator on call "why aren't we looking at the Log Tags every day to ensure proper RH and temperature levels and fix the problem?"

Review of a Patient Care Event report occurred on July 24, 2013 and identified the following:
*05/16/13: ". . .Event date and time: 05/15/13 [11:45 a.m.] . . . Description of the Event: A [laparoscopic] [appendectomy] was added on the surgery schedule to follow [name of physician]'s case and because it has been a busy day, Rooms 1 and 2 were not available and Room 3 was left open for a possible C-section, the only available room was Room 4, there has been an issue all week with the air in Room 4 and maintenance was contacted more than once in regards to this issue. The last time they were contacted was yesterday and it was reported that it was corrected. When we opened and set the room up for the case, brought the [patient] in and noticed that there was not any air movement in the room and it was starting to get very warm, maintenance was called again and they said they needed to go into the room after this case but would try to resolve the issue from an outside source. The problem was not fixed and the case went on but without the proper air exchange. This is vital to infection rate and sterility of the field. The OR should have been notified when the problem was unable to be fixed. This lack of communication between maintenance and the OR is beyond unacceptable because infection control in the OR is a very important part of patient safety and we absolutely need to be notified when the air quality of a room is jeopardized. . . . Immediate Actions Taken: Notified Maintenance . . . Patient Name: [Patient #4] . . . Room: OR #4 . . . Comments: Maintence (sic) must notify department managers when work will effect departments. . . . Initial Contributing Factors: Maintenance did not notify the OR that the air quality in OR 4 was not fixed. . . ."

Review of the OR log confirmed the above surgical procedure performed on Patient #4 on 05/16/13, showing the patient underwent a laparoscopic appendectomy from 10:55 a.m. to 12:54 p.m.

Review of retrievable log tag data prior to the event in July identified the OR had issues with RH in June 2013 and showed the following readings:
*OR #1: RH greater than 60% on June 25-26 (ranges from 63 to 72.6%).
*OR #3: RH greater than 60% on June 25, 26, 27, 28, and 29 (ranges from 62 to 70.3%).
*OR #2: RH greater than 60% on June 25 and 26 (ranges from 62 to 68.5%); June 27, 28, 29, and 30 (ranges from 61 to 66.8%).

Review of retrievable log tag data since the July event showed RH issues continued in the OR and showed the following:
*OR #1: RH greater than 60% on July 08-09 (ranges from 62 to 88.1%); July 10, 13, and 15 (ranges from 62 to 70.2%); and July 16, 17, and 18 (ranges from 61 to 73.1%).
*OR #3: RH greater than 60% on the morning of July 08 (ranges from 61 to 71.4%).

During an interview on 07/24/13 at 12:20 p.m., two OR staff members (#1 and #3) stated administration advised OR staff to turn up the temperature in the OR rooms to drive the RH down. A staff member (#3) identified a temperature of 70 degrees in OR #2 on Sunday (July 21, 2013) and stated the surgeon (#10) was "drenched" and she had to "wipe his brow" during the surgery because of perspiration interfering with his ability to perform. Review of the OR log confirmed the surgeon (#10) mentioned in the above interview with an OR staff member (#3) performed an open reduction internal fixation and intramedullary rodding of the right tibia on Patient #11 on 07/21/13 from 8:45 a.m. to 11:25 a.m. in OR #2.

Review of the readings monitored by the maintenance department during the week following the event in July showed the temperature levels were above the recommended range outlined in the e-mail sent to the providers and anesthesia staff in response to the event. The readings showed the following:
*July 08 - 71 to 72.5 degrees Fahrenheit (F) from 11:00 a.m. to 8 p.m.
*July 09 - 71.9 F from 12:00 a.m. to 4:00 p.m.
*July 10 - 72 to 74.8 F from 12:00 a.m. to 8:00 p.m.
*July 11 - 70.9 - 73 F from 12:00 a.m. to 8:00 p.m.
*July 12 - 72.5 to 74.6 from 12:00 a.m. to 4:00 p.m.

Review of log tag readings for July 2013 revealed increased temperature in the OR and showed the following:
*July 10-17 - Temperature range of 71-74.8 F in OR #2.
*July 08-19 ; Temperature range of 71-74.7 F in OR #3.

During an interview on 07/24/13 at 2:30 p.m., an administrative maintenance staff member (#4) stated the CAH has not had any problems with high humidity in the OR prior to or since the event which occurred the first week in July. He stated the recent issues with increased temperature in the OR rooms are due to staff not following the guidelines proposed for controlling the temperature. At 3:30 p.m., an administrative staff member (#6) also identified no problems with the chiller or high humidity in the OR since the event. He stated staff must follow the guidelines proposed for controlling the temperature in the OR to alleviate issues with increased temperature and humidity. The staff member (#6) stated the log tag system implemented by surgical department staff as inaccurate and stated the CAH does not follow AORN standards.

During an interview on 07/24/13 at 4:00 p.m., an administrative staff member (#5) stated the CAH failed to develop and implement a policy and procedure in relation to the plan proposed for setting temperatures in the OR rooms following the event and did not ensure OR staff properly implemented the plan for setting temperatures in the OR.

During an interview on 07/24/13 at 5:30 p.m., an administrative maintenance staff member (#4) confirmed the CAH's air handling system would not alert or alarm during times of high humidity and stated the system required staff to manually check humidity levels to ensure the levels within recommended ranges.

The CAH monitored RH once a month in one OR room (OR #2) even though the CAH performed surgeries in all six OR rooms on all days of the week. After the event in July in which the RH in the OR became very high, the CAH monitored the RH more frequently in four OR rooms for a period of four days, then went back to monthly monitoring in one OR room as before. In an effort to decrease the RH, the temperature of the OR rooms increased causing staff concerns such as perspiration and discomfort during surgeries. Log tag data, incident reports, and staff interviews regarding RH levels in the OR indicate problems with the air handling system prior to and after the July event. Failure to monitor RH in all Operating Rooms limited the CAH's ability to ensure the RH did not exceed 60% on all days staff performed surgery. The CAH failed to follow standards and recommendations set forth by nationally recognized professional organizations and failed to develop and implement a process to ensure acceptable RH levels in the OR and ensure appropriate and comfortable temperature levels in the OR.

2. Based on observation, review of professional literature, review of Patient Care Event reports, review of the OR log, record review, and staff interview, the Critical Access Hospital (CAH) failed to perform surgical procedures in a safe manner by failing to maintain a sterile environment for 4 of 6 operating room (OR) suites (OR #2, #3, minor and cystoscopy (cysto) room) with reports and observations of un-clean surfaces. Failure to maintain clean OR suites limited the CAH's ability to ensure a sterile environment and placed patients at risk of contamination during surgical procedures.

Findings include:

"Guidelines for Construction and Equipment of Hospital and Medical Facilities," 1992-93 edition, Chapter 7, Section 7.28, Subsection 7.28.B. Finishes stated, ". . . 7.28.B6. Wall finishes shall be washable. . . . In operating rooms, delivery rooms for caesarean sections . . . wall finishes shall be free of fissures, open joints, or crevices that may retain or permit passage of dirt particles. . . ."

- During observation of the OR in the afternoon on 07/23/13, an administrative surgical staff member (#1) stated the surgical department maintained and utilized six OR rooms; OR #1-4, a "minor" and a "cysto" room. Observation of OR #3 and the minor and cysto rooms showed the walls of each suite covered in wallpaper/vinyl with visible seams peeling and breaking loose from the wall. Further observation in the minor room showed a hole in the wall to the right of the doorway upon entrance to the room, and another hole covered with masking tape up the side of the same wall.

Review of the OR log from May through July 2013 occurred on 07/23/13 and showed the CAH performed an average of six to 18 surgical procedures a day during the week, and two to six during the weekends, utilizing all six OR rooms. The surgical procedures performed at the CAH ranged from general, orthopedic, obstetric, and gynecological surgeries, to endoscopy, cystoscopy, and pain management procedures.

During an interview on 07/24/13 at 2:00 p.m., an administrative maintenance department staff member (#4) stated he did not know of the damage to the walls in the OR suites in the surgical department.

- Review of Patient Care Event reports occurred on July 23-24, 2013 and identified the following:
*07/11/13: ". . . Event date and time: 07/11/13 [2:15 p.m.] . . . Description of the Event: After the procedure was completed and dressings were on a knat [sic] was found walking on the sterile backtable . . . [name of Patient #20] . . . OR 2 . . . Comments: Instructed staff to monitor and make sure all outside access doors are closed. . . . Comments: Discussed at daily safety checkin. Noted garage door has not been getting closed. will inform staff to all take responsibility if door is open to close it. . . ."
*07/19/13: ". . . Event date and time: 07/18/13 [11:00 a.m.] . . . Description of the Event: I found fruit fly roaming around in surgical room 2. . . . [name of Patient #9] . . . Room 2 . . . Comments: Reviewed by [name of administrative staff member], visited with environmental services [ES] regarding process for insect removal. . . . Comments: ES concerned that OR personal [sic] are leaving the building with scrubs on and have been witnessed smoking off hospital grounds near trees, question if this could be how the insects are entering the OR. . . . Initial Contributing Factors: Warm temperature in surgical room. . . ."
*07/19/13: ". . . Event date and time: 07/18/13 [2:00 p.m.] . . . Description of the event: I found fruit fly roaming around in OR 2. . . . [name of Patient #10] . . . Room 2 . . . Comments: Completed assessment by [name of administrative staff member]. Had conversatio [sic] with ES manager she will investigate . . . Comments: Concern that the OR staff is leaving the building and some have been witnessed smoking with OR clothes on. This may be a host for entry into the OR. . . . Initial Contributing Factors: Warm temperature in surgical room . . ."

During an interview on 07/24/13 at 3:05 p.m., an environmental services staff member (#9) stated she knew nothing of the incident with the gnat and stated her concern with OR staff leaving the building to smoke. She identified a pest control company visited the CAH every four to six weeks to perform surveillance and stated staff could notify the company for any issue. The staff member (#9) reported the CAH had not contacted the company in regard to the above incidents.

During an interview on 07/24/13 at 3:20 p.m., an administrative nurse (#5) stated staff forwarded concerns with fruit flies and OR staff leaving the building to smoke to an administrative anesthesia staff member (#11) for review, but identified administrative staff members had not yet addressed the concerns. She stated staff discovered a door located by the emergency department (ED) propped open often or "left open by the ambulance after bringing patients to the ED" and thought this to be a point of entry for insects into the CAH. The staff member (#5) stated the CAH installed a camera by the ED desk as a way for staff to view the door and ensure closure, but could not provide information whether staff members performed the monitoring and how often the monitoring occurred.

Observation of the hallway outside the surgical department occurred on 07/24/13 at 5:00 p.m. and identified the ED as a good distance away fro