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Based on observation, record review, and interview, the provider failed to maintain proper temperature and humidity control for one of one operating room (OR). Findings include:

1. Review of surgical charts revealed:
*Patient 10 had surgery on 1/6/11. The OR temperature was 75 degrees Fahrenheit (F).
*Patient 11 had surgery on 11/23/10. The OR humidity recorded on 11/22/10 was 22 percent (%).
*Patient 12 had surgery on 9/23/10. No OR temperature or humidity were recorded.

Review of the OR Temperature and Humidity Log revealed:
*On 3/11/10 - Temperature 63 degrees F.
*On 6/10/10 - Humidity 62%.
*On 8/26/10 - Temperature 67 degrees F.
*On 10/7/10 - Temperature 65 degrees F.
*On 11/22/10 - Humidity 22%.
*On 1/6/11 - Temperature 75 degrees F.
*On 1/13/11 - Temperature 75 degrees F and humidity 25%.
*On 2/10/11 - Humidity 21%.
*On 2/24/11 - Humidity 29%.

Interview on 2/24/11 at 9:45 a.m. with out patient coordinator registered nurse (RN) B revealed she was unsure what the recommended temperature and humidity ranges were. Further interview on 2/24/11 at 11:00 a.m. with RN B revealed:*They used a portable humidiguide in the OR with temperature and humidity gauges.
*The temperature and humidity were recorded on the OR Temperature and Humidity Log.
*There was a thermostat in the OR to adjust the temperature up or down.
*There was a humidity control in the OR, but she had never touched it.
*There was no policy related to temperature or humidity levels for in the OR.

Interview on 2/24/11 at 11:15 a.m. with director of plant operation C revealed he was not aware there was a problem with the temperature and humidity levels in the OR. No problems had been reported to him.

Review of Association of periOperative Registered Nurses Perioperative Standards and Recommended Practices, 2010 edition, p. 221, revealed relative humidity should be maintained between 30% and 60% within operating rooms. Temperature should be maintained between 68 degrees F to 73 degrees F within the operating room suite.

Based on interview, program review, and policy review, the provider failed to ensure all patient care services were evaluated as needed for the health and safety of patients. Findings include:

1. Review of the provider's current Performance Improvement Program revealed no evaluation of the laundry service and waste removal service.

Interview on 2/23/11 at 1:15 p.m. with director of health information A confirmed the laundry service and waste removal service were not included in the provider's quality assurance program.

Review of the provider's Performance Improvement Program/Policy revised January 2011 revealed the performance improvement program was designed to objectively and systematically monitor, evaluate, and improve the services offered.