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Based on observation, interview and record review, the Governing Body failed to ensure the facility's HVAC (heating, ventilation, and air conditioning) was adequately maintained in the Perioperative area (where the two operating rooms, recovery room, and surgical supply storage rooms were located), which caused the storage rooms to be below facility temperature parameters. Facility staff placed a space heater in the Sterile Storage Room and Anesthesia Room (supply storage rooms) and ran the space heaters, unsupervised, and on a continuous bases for approximately three months. This caused potential for improper storage of surgical supplies and accidental fire in the Perioperative area, which endangered all patients, staff and visitors who were in the facility during that three-month period.

Findings:

During an observation and concurrent interview in the perioperative Sterile Supply Room on 12/6/18 at 10:55 a.m., a portable space heater was located on the floor; the heater was turned on and running. Manager Q stated the facility's HVAC system had a, "bad" heating coil, and the portable heater was being used (to maintain temperature). When asked how long the portable heater was in use, Management Staff Q stated it had been a few weeks. During an observation at 11:25 a.m., a second space heater was located on the floor in the perioperative Anesthesia Room; the heater was turned on and running. Manager Staff Q was asked how long the two heaters ran per day, and he stated, "I don't know." When asked who monitored the two space heaters, Manager Staff Q stated nursing staff monitored them.

Review of the the facility's perioperative log titled, "Temperature/Humidity/Air Flow Monitoring Log," indicated the temperature and humidity in, "all perioperative areas" was, "temperature: 65-72°F (Fahrenheit)" and "humidity: 30-60%." Review of facility perioperative logs (dated 7/1/18 through 11/30/18) revealed the following: OR 1 humidity was outside parameters on approximately eleven occasions; OR 2 temperature and humidity was out of parameters on approximately fourteen and nineteen occasions, respectively; sterile supply room and anesthesia room's temperature and humidity were out of parameters on approximately six and ten occasions, respectively. Review of December 2018, sterile supply room logs indicated temperatures were our of compliance seven of eleven times tested.

During an interview on 12/6/18 at 12:25 p.m., the Facilities Director (Manager DD) was asked about the space heaters operating in the perioperative area. Manager DD stated the facility's HVAC had a burned out coil inside the air duct. When asked when the HVAC coil burned out, he stated he did not know (his employment at the facility began less than one month earlier). When asked about the safety of space heaters, Manager DD stated the heaters were low temperature and had a control mechanism. Manager DD was asked how his department monitored the space heaters, and he stated he relied on staff to tell him the room temperatures.

During an interview on 12/6/18 at 3:30 p.m., Manager DD stated the facility had no documentation from the prior maintenance director (Manager U), regarding the HVAC maintenance issue or the use of space heaters in the perioperative area. Manager DD stated Staff EE informed him the space heaters had been in use in the perioperative area approximately three months.

During an observation and concurrent interview in the perioperative department on 12/6/18 at 4 p.m., Manager Q was asked about the space heaters in the two supply rooms. Manager Q agreed the sterile storage space heater titled, "Comfort Zone" had a label that indicated, "Do not leave unattended" and "Not for industrial use..." Manager Q agreed the anesthesia room space heater titled, "Duraflame" had a label that indicated, "Fire hazard."

During a policy review and interview 12/6/18 at 4:20 p.m., in the Quality Assurance office, Manager DD reviewed the manufacture's guidelines for the Comfort Zone space heater (located in the sterile supply room), and he agreed the facility was not using the device per manufacturer's guidelines (specifically, the guidelines indicated the space heater was for residential/office use only, not for industrial or other commercial application; and the space heater was not to be used, "unattended.") Manager Q stated he would return to the perioperative area and unplug the two heaters. Manager Q, Manager DD, and Manager FF stated they would stop using the space heaters and monitor the temperatures and humidity levels in the perioperative areas.

Review of the Comfort Zone manufacturer's guidelines titled, "Compact Ceramic Heater," subtitled, "Intended Use"(undated), indicated the product was, "intended for indoor residential and office use only....Risk of fire, over heating, malfunction..." Under subtitle, "Important Instructions," the guidelines indicated, "Do not use heater unattended...A heater has hot and arcing or sparking parts inside...Use this heater only as described in this manual. Any other use not recommended by the manufacturer may cause fire, electric shock or injury to persons or property." Under subtitle, "Warning: Fire Hazard," the guidelines indicated, "Heater has hot and arcing or sparking parts inside. Do not use near combustible materials or flammable gasses..."

During an interview on 12/10/18 at 9 a.m., Staff EE was asked about the history of the HVAC issues related to the perioperative area. Staff EE stated a reheating coil, "went out" in the ducting that affected the sterile storage and anesthesia rooms. Staff EE stated the prior Facilities Manager had gotten a proposal for a new reheating coil, but had put the order of a new coil, "on hold." Staff EE stated the facility had put in the portable space heaters into the storage rooms to maintain (appropriate) temperatures and to buy time until the heating coils were fixed. Staff EE stated the two space heater were left plugged in and ran continuously.

During an interview on 12/10/18 at 11 a.m., the COO (Chief Operating Officer) stated the HVAC heating coil went out about three months ago. He stated he was only notified space heaters were being used to maintain proper temperatures the prior week. The COO stated the facility had requested a permit to repair the system.

During an interview on 12/10/18 at 4 p.m., Governing Body Member H (GB H) stated the facility had not had a Governing Body meeting since new management had taken over the facility (approximately 9/18). She stated a District Board meeting had been held on 12/3/18, but the issue of temperature/humidity (and use of space heaters) in the perioperative area had not been discussed. She stated the HVAC was on the building maintenance, "to do" list.

During an interview on 12/11/18 at 9:45 a.m., Physician X (perioperative director) was asked about space heater use in the perioperative areas. Physician X stated he was not aware of the space heater's usage until the day prior (12/10/18), and stated use of space heaters was, "not a great idea" in hindsight.

Review of facility policy titled, " Portable Heating Devices" (revised 11/2017), indicated the policy's purpose was to, "establish a policy that prohibits the use of portable heating devices." The document indicated the facility supervisors were responsible for ensuring the policy was, "strictly adhered to." Under the subtitle, "Procedure," the policy indicated, "should the environmental conditions exist which necessitate additional heating capabilities, the Facilities Management department will be notified in order to investigate the cause of the problem."

Review of facility policy titled, "Governing Body (GB)," subtitled, "GB.1 Legal Responsibility" (revised 2/5/18), indicated the governing body, "is responsible for all services provided in the organization..." The policy indicated the governing body is accountable for ensuring that..."SR.1a. The organization is in compliance with all applicable Federal and State laws and in accordance with organization policies and procedures regarding the health and safety of its patients..."

According to AORN (Association of periOperative Registered Nurses), free-standing fans...should not be used. These devices contain, "a fan that when running can disrupt the planned airflow within the room and may transfer unwanted particles from the floor..."
(https://aornguidelines.org/guidelines/content?sectionid=173721980&view=book)

Online review of AORN document titled, "AORN Facility Reference Center Guidelines for Perioperative Practice: Environment of Care, Part 2" (copyright 2012-2018), indicated, "IV. The health care organization should create and implement a systematic process for monitoring HVAC (heating,ventilation, and air conditioning) performance parameters and a mechanism for resolving variances." The document indicated HVAC systems control room air quality, temperature, humidity and air pressure of a room. The HVAC system is, "intended to reduce the amount of environmental contaminates ..."