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Based on observation and interview it was determined the corridor in the Basement Surgical Department was obstructed to prevent the full and instantaneous use of the corridor. The failed practice had the potential to affect all surgical patients and staff because the ability to quickly remove patients and staff from the area in the event of an emergency was impeded by the equipment located in the corridor. The facility performed an average of 800 surgeries per month and had 48 patients scheduled for surgery on 02/24/14. The findings follow:

A. Observation on a tour of the basement surgical department on 02/26/14 at 1315 with the OR Director, OR Manager, and RN #1 revealed the following items located in the corridor outside Operating Rooms #1, #2, #3, #6, #9, and #10:
1) Laundry cart
2) Two metal baskets
3) Vital signs monitor
4) Pump
5) K-thermia machine
6) Sterile pack
7) Linen cart
8) Emergency cart
9) Pyxis supply machine
B. The above items were also observed on a tour of the area on 02/28/14 at 1200. The OR Director, OR Manager, and RN #1 verified the items were observed in the corridor.

Based on Surgery Temperature and Humidity Log review and interview it was determined the facility failed to take corrective action in response to relative humidity readings outside the required range (30% to 60% per Rules and Regulations for Hospitals and Related Institutions in Arkansas (2007 edition) in two of three Operating Departments in February 2014 and July 2013. Humidity levels outside the required range had the potential to affect the health and safety of all patients admitted for surgery due risk of sparks from static electricity build-up associated with low humidity and the increased risk of bacterial growth and compromised integrity of wrapped sterile supplies associated with an excessively humid environment. The facility performed an average of 800 surgeries per month and had 48 patients scheduled for surgery on 02/24/14. The findings follow:

A. A review of the Surgery Temperature and Humidity Log review for the months of February 2014 and July 2013 for the Basement Surgery Department, Third Floor Ambulatory Surgery Department and the Labor and Delivery Department on 02/25/14 at 1045 revealed the following:
1) For the Basement Surgery Suite, relative humidity out of range was recorded on 11 of 24 days in February 2014 and 23 of 31 days for the Third Floor Ambulatory Surgery in July 2013. There was no documentation the Engineering Department was notified to take corrective action.
2) For the Third Floor Ambulatory Surgery Department, relative humidity out of range was recorded on 11 of 24 days in February 2014 and 12 of 31 days in July 2013. Notification of the Engineering Department was not documented in February 2014.

B. In an interview on 02/26/14 at 1000 the Engineering Supervisor and Vice President of Facility, Risk, and Safety Management verified the Engineering Department had not received notification of the out of range humidity and there was no documentation of corrective action taken.

Based on observation and interview it was determined the corridor in the Basement Surgical Department was obstructed to prevent the full and instantaneous use of the corridor. The failed practice had the potential to affect all surgical patients and staff because the ability to quickly remove patients and staff from the area in the event of an emergency was impeded by the equipment located in the corridor. The facility performed an average of 800 surgeries per month and had 48 patients scheduled for surgery on 02/24/14. The findings follow:

A. Observation on a tour of the basement surgical department on 02/26/14 at 1315 with the OR Director, OR Manager, and RN #1 revealed the following items located in the corridor outside Operating Rooms #1, #2, #3, #6, #9, and #10:
1) Laundry cart
2) Two metal baskets
3) Vital signs monitor
4) Pump
5) K-thermia machine
6) Sterile pack
7) Linen cart
8) Emergency cart
9) Pyxis supply machine
B. The above items were also observed on a tour of the area on 02/28/14 at 1200. The OR Director, OR Manager, and RN #1 verified the items were observed in the corridor.

Based on Surgery Temperature and Humidity Log review and interview it was determined the facility failed to take corrective action in response to relative humidity readings outside the required range (30% to 60% per Rules and Regulations for Hospitals and Related Institutions in Arkansas (2007 edition) in two of three Operating Departments in February 2014 and July 2013. Humidity levels outside the required range had the potential to affect the health and safety of all patients admitted for surgery due risk of sparks from static electricity build-up associated with low humidity and the increased risk of bacterial growth and compromised integrity of wrapped sterile supplies associated with an excessively humid environment. The facility performed an average of 800 surgeries per month and had 48 patients scheduled for surgery on 02/24/14. The findings follow:

A. A review of the Surgery Temperature and Humidity Log review for the months of February 2014 and July 2013 for the Basement Surgery Department, Third Floor Ambulatory Surgery Department and the Labor and Delivery Department on 02/25/14 at 1045 revealed the following:
1) For the Basement Surgery Suite, relative humidity out of range was recorded on 11 of 24 days in February 2014 and 23 of 31 days for the Third Floor Ambulatory Surgery in July 2013. There was no documentation the Engineering Department was notified to take corrective action.
2) For the Third Floor Ambulatory Surgery Department, relative humidity out of range was recorded on 11 of 24 days in February 2014 and 12 of 31 days in July 2013. Notification of the Engineering Department was not documented in February 2014.

B. In an interview on 02/26/14 at 1000 the Engineering Supervisor and Vice President of Facility, Risk, and Safety Management verified the Engineering Department had not received notification of the out of range humidity and there was no documentation of corrective action taken.