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Rush Memorial Hospital was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 485.623(c), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies.

Based on record review and interview, the facility failed to ensure the humidity in 2 of 3 anesthetizing locations were maintained between 20% and 60% and within the relative humidity range established in surgical services policy documentation (see tag K323).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on record review and interview, the facility failed to ensure the humidity in 2 of 3 anesthetizing locations were maintained between 20% and 60% and within the relative humidity range established in surgical services policy documentation. NFPA 99 9.3.1.1 requires heating, cooling, ventilating, and process systems serving spaces or providing health care functions covered by this code or listed within ASHRAE 170, Ventilation of Health Care Facilities. ASHRAE 170, requires mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 20 percent or greater. CMS requires Operating Rooms not to exceed 60% humidity per S&C 13-25-LSC. This deficient practice could affect staff and up to 2 patients.

Findings include:

Based on review of relative humidity documentation for January 2020 through August 2020 with the Vice President of Operations and the Facilities Director from 10:15 a.m. to 12:30 p.m. on 09/29/20, documentation of the relative humidity in Operating Room 1 was greater than 60% for 06/08/20 through 06/12/20. Relative humidity in Operating Room 2 was at 16% on 01/17/20 and was greater than 60% for 05/26/20 through 05/29/20. Based on review of "Standards for Patient Care in Anesthesiology Policy" dated February 2020, Policy 3.3.5 states "relative humidity shall be kept at not less than 50%". Based on interview at the time of record review, the Vice President of Operations stated Operating Rooms 1 and 2 can be used for general anesthesia, the Anesthesiology Policy contains reporting to maintenance as the corrective action when relative humidity is not maintained, she was unaware of why 50% was established as a relative humidity minimum for the rooms and agreed relative humidity documentation showed relative humidity had been exceeded for both 50% and 60% and was below 20% on 01/17/20.

This finding was reviewed with the Vice President of Operations at the exit conference.