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Based on observation, staff interview, review of the facility's policies and records, the facility failed to ensure all the electrical equipment in the operating room receive current up to date Biomedical inspections.

Findings include:

Observation conducted of the Operating Room (OR) Suites located on the second floor of the facility on 01/13/2014 between 1:00 AM and 2:30 PM, disclosed of the "high performance water-cooled air conditioners" utilized by Surgeon #1 during procedures in the operating rooms does not have any evidence record/label of biomedical checks or filter changes performed by the facility.

An interview was conducted on 01/13/2014 at 1:45 PM. with the OR Assistant Manager, RN, who is in charge on said date. The OR Manager stated, "the portable air conditioners used by the surgeon are stored in the maintenance department and brought up by maintenance for the surgeon's cases. He usually works here about once per week and brings multiple cases. They are in the room, when I come in the mornings, when the surgeon is scheduled to work. They are used to cool the rooms for surgeon comfort. He does not have any cases scheduled for today or tomorrow".

An additional interview was conducted on 01/13/2014 at 2:45 PM with the Facility Manager, who is in charge of the physical plant plans including the Biomedical testing done by the facility. The Facility Manager stated,"The high performance water cooled air conditioners used by Surgeon #1 are stored in the maintenance department and brought to the OR for use when needed. We have had the air conditioners for a couple of years, there are no records of Biomedical checks or preventative maintenance for those units."

Based on observation, staff interview, and review of the facility's policy and procedures, the facility failed to follow policy based on AORN standards related to Operating Room maintenance, specifically related to "Traffic Standards in the Surgical Suite". This is evidenced by performing surgical procedures with the OR doors open to the substerile area.

Findings include:

Credential file disclose, Surgeon #1 is credentialed by the facility in orthopedic surgery and specializes in hand surgery. Included on preference cards for Surgeon #1 is a mobile "high performance water-cooled air conditioner". The unit is used to lower the temperature in the Operating Room for surgeon comfort. The surgeon operates at the facility weekly and utilizes OR #3 and #4 for his cases.

Observation was made of the mobile "high performance water-cooled air conditioner" on 01/13/2014 at approximately 2:00 PM. The pertinent specifications for the unit reveal the following:
19 1/4 inches wide and 18 1/2 inches deep
Electrical power cord- 10-13 feet
3 water cooled hoses- for water supply connection, water return connection and condensate connection.
The unit lowers temperature by water flow over coils.

An interview was conducted with Registered Nurse (RN) #1, who is a circulator in the operating room on 01/13/2014 at 1:15 PM. The RN provided the following information,"The surgeon utilizes the airconditioner during most of his cases. The maintenance staff brings the unit up in the mornings and they hook the hoses to the facet of the sink in the substerile room. The hoses prevent the OR doors from closing during his cases and we have one air conditioner in each room while he is working. The door remains ajar for the entire case, probably about 12 to 14 inches. It also hooks to the sink, therefore we do not have a sink for use in the substerile room during his cases. We have identified our concerns to the OR manager but the surgeon brings a lot of cases to the hospital."

An interview was conducted with Registered Nurse #2 , who is a circulator in the operating room on 01/13/2014 at approximately 2:00 PM. RN #2 provided the same information regarding the air conditioner unit in the OR's during the cases for Surgeon #1.

An additional interview was conducted with the Certified Registered Nurse Anesthetist (CRNA) on 01/14/2014 at 12:00 PM. The CRNA confirms that she most often works with Surgeon #1. She also confirmed that the doors to the substerile room (usually OR #3 and OR#4) are both open during the surgeons cases. She further stated,"We loose use the use of the sink and if handwashing is needed we have to go out into the main hall to the sink there."

A review was completed of the facility's policy and procedure,"Traffic Patterns in the Surgical Suites", most recently reviewed and revised 11/13/2013. The policy provides guidelines for maintaining an aseptic environment in the surgical suites. The following information is found in the policy:
"2. Movement of personnel should be kept to an absolute minimum while surgery is in progress.
A. All doors to an Operating Room must be closed except when entering or exiting a room.
B. Where physically possible, entry to the Operating Room should be through the side door (sub-sterile area for all personnel) once a procedure has begun. The patient and equipment should enter through the main door of the Operating Room"

An interview was conducted with the facility Risk Manager and Epidemiologist on 01/13/2014 at 3:15 PM. Both the Risk Manager and Epidemiologist stated, they did not realize the air conditioner unit required the door to remain open during the surgical cases and acknowledged that it is not standard of care for an operating room door to remain open during surgical procedures.