This policy, revised September 2000, stated, "Policy: Prevention of indirect and direct transmission of infectious disease is imperative in the OR." Review of the policy, "Infection Control Guidelines for Surgery and Recovery Room," occurred on July 24, 2013.
Due to the fact excessive humidity is conducive to microbial growth and compromises the integrity of wrapped sterile instruments and supplies, failure to monitor RH levels within the surgical department and ensure the RH did not exceed sixty percent placed patients at an increased risk of surgical site infection. Based on observation, review of professional literature, review of Patient Care Event reports, review of electronic mail (e-mail) communication, review of Operating Room (OR) logs, policy and procedure review, review of humidity logs, and staff interview, the Critical Access Hospital (CAH) failed to perform surgical procedures in a safe manner by failing to maintain compliance with applicable regulations and guidelines governing surgical services, including standards and recommendations established by nationally recognized professional organizations, to monitor and ensure relative humidity (RH) levels in the surgical department did not exceed the recommended range of 60 percent for 3 of 3 months (May, June, and July 2013) reviewed. Information on doing so is available here. Accessing the document may require you to file a Freedom of Information Request. For that information, you should contact the hospital, your state health department or CMS. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction.
The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services.
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