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Based upon observation, interview and document review the Critical Access Hospital (CAH) failed to ensure the humidity level was maintained within the acceptable target range as determined by the CAH. This had the potential to affect any patient who had procedures in the operating room (OR) suite.

Findings include:

According to the CAH staff, the acceptable level of humidity was determined to range from 30-60% in the OR suite. The CAH lowered the humidity level standard to 20% to 60% on July 1, 2015. When OR humidity logs were reviewed along with the quarterly quality assurance (QA) report, it was noted the humidity level often was not within the acceptable range. The CAH did not ensure the humidity level in anesthetizing locations were maintained within acceptable standards to inhibit microbial growth, reduce risk of infection, control odor and promote patient comfort.

During a tour of the surgical suite on 7/6/15, at 12:45 p.m., it was noted that a digital temperature and humidity monitoring device (Extech brand) was located in OR #1. The monitoring device measured the humidity at 70%. The Extech humidity monitoring device was again observed the following day, on 7/7/15, at 12:45 p.m. and the humidity level remained at 70%. During observation of a surgical procedure in the OR on 7/10/15, at 9:18 a.m., the Extech monitoring device indicated the humidly level in the operating room was measured at 55%.

The surgical services manager (SSM) was interviewed on 7/6/2015 at 1:00 p.m. and stated the CAH had established the target/goal related to humidity levels to be between 30% to 60%. She stated they had been unable to meet the targeted goal for the past year because the humidity level within the OR varied from day to day and season to season.

A review of a Humidity Sheet designated for OR, the log revealed the humidity levels in the OR were monitored at least six times a month from 6/26/2014 until 6/30/2015. A QA log which covered July 1, 2014 to June 30, 2015 documented the quarterly results obtained from the OR Humidity monitoring sheets. The first (1st) quarter (July 1-September 30, 2014) indicated the humidity was within acceptable or target range only 38% of the time; the second (2nd) quarter (October 1-December 31, 2015) revealed the humidity levels were within the acceptable range only 19% of the time; the third (3rd) quarter (January 1-March 31,2015) the humidity levels were within the target range only 7% of the time; and the fourth (4th) quarter (April 1-June 30, 2015) only 64% of the time. The QA report also indicated the humidity in the OR was only within the target goal range (30-60% humidity) only 26% of the time when the readings were logged, the prior fiscal year.

When interviewed on 7/6/15, at 1:00 p.m. the SSM stated the humidity monitoring device had been purchased at a hardware store and was unsure whether it was accurate. She stated the hospital maintenance department did not monitor the temperature nor the humidity in the OR suite and stated the OR nurses had begun monitoring the humidity level almost daily as the humidity levels seemed to change significantly from day to day. The SSM further indicated the director of maintenance had been notified of the variations in the humidity readings.

When interviewed on 7/10/15, at 10:15 a.m. the director of maintenance stated he was aware there had been concerns related to the humidity levels in the OR suite and confirmed that maintenance staff did not monitor the humidity levels to ensure the ventilation systems were maintained within acceptable standards.

Based on observation, interview and document review the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the CAH.

Findings include:

Please refer to Life Safety Code inspection tags: K18, K52, K56 and K147.

Based upon interview, record review and document review the Critical Access Hospital (CAH) failed to ensure a pre-anesthesia evaluation was completed for 1 of 6 surgical patients (P-1) and a post-anesthesia evaluation was completed for 1 of 6 surgical patients (P-2) whose records were reviewed. This had the potential to affect any patient who had anesthesia at the CAH.

Findings include:

Documentation of pre-anesthesia and post-anesthesia evaluations, completed by the certified registered nurse anesthetist (CRNA) who provided anesthesia coverage the the CAH, were missing.

P-1 had an inpatient surgical procedure on 6/19/15 under general anesthesia administered by CRNA-A. There was no pre-anesthesia evaluation completed in the electronic medical record (EMR). Registered nurse (RN-A) was interviewed on 7/7/15, at 2:30 p.m. and verified there was no pre-anesthesia evaluation documented in the EMR.

P-2 had an inpatient surgical procedure on 5/17/15, under general anesthesia administered by CRNA-B. There was no post-anesthesia evaluation completed in the EMR. RN-B was interviewed on 7/9/15, at 2:30 p.m. and verified there was no post-anesthesia evaluation documented in the EMR.

A review of the policy Anesthesia Risk Pre-operative and Post-operative Evaluation, last revised August 2012, indicated each patient was evaluated by the CRNA prior to the administration of anesthesia. The policy also indicated the CRNA would write a comprehensive post anesthesia follow-up note following the surgical procedure. The policy indicated the note would be located in the patient's EMR.

When interviewed on 7/9/15, at 3:05 p.m. the certified registered nurse anesthetist (CRNA)stated the pre-anesthesia and post-anesthesia evaluations were to be documented in the EMR for each patient undergoing a surgical procedure which required anesthesia.