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Healthcare Inspection – Environment of Care and Safety Concerns in Operating Room Areas, Edward Hines Jr. VA Hospital, Hines, Illinois

Report Information

Issue Date
Report Number
14-05173-92
VISN
State
Illinois
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
4
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG conducted an inspection at the request of Senator Mark Kirk to assess allegations of environment of care and safety concerns at the Edward Hines Jr. VA Hospital, Hines, Illinois. We substantiated the allegation that water had flooded the new surgical operating room (OR) areas and that mold was present. The water infiltration problem was resolved and the mold was remediated prior to the OR’s first use for patient care. We substantiated the allegation of years of flooding and water damage in the old OR. We observed that no patient care was being conducted in this area. We substantiated the allegation that the overhead paging and emergency system was not audible throughout the entire surgical OR area. Review of patients’ electronic health records noted no delays in initiating the codes. We substantiated the allegation that the adjustment of temperature and humidity in new OR areas was difficult to control. We substantiated the allegation that surgical booms located in the new OR were difficult to manipulate and maneuver around. We did not substantiate the allegation that opening of the OR doors required staff to use their backs to push into the doors. We recommended that the Acting Facility Director: (1) implement an action plan to remediate water damage in the basement of Building 200; (2) initiate a safety analysis of the current overhead paging and emergency system for communication of a code throughout the entire surgical OR, including the post anesthesia care units, and take action as necessary; (3) implement processes to maintain recommended ranges for temperature and humidity in OR areas; and (4) take actions to prevent staff injury from surgical booms in ORs.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Acting Facility Director implement an action plan to remediate water damage in the basement of Building 200.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Acting Facility Director initiate a safety analysis of the current overhead paging and emergency system for communication of a code throughout the entire surgical operating room, including the post anesthesia care units and take action as necessary.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Acting Facility Director implement processes to maintain recommended ranges for temperature and humidity in operating room areas.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Acting Facility Director take actions to prevent staff injury as a result of surgical booms located in operating rooms.