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Based on record review and interview, the hospital failed to ensure appropriate ventilation and humidity levels were maintained in the endoscopy suite (see LSC K323). This failed practice has the potential to cause HAIs in patients receiving endoscopic procedures due to creation of an environment more conducive to microbial growth.

Findings:

The surveyor reviewed a policy titled "Infection Control in Endoscopy", which read in part:

"Air changes per hour, humidity and temperature ranges comply with the most current ventilation requirements published by the Oklahoma State Department of Health..."

"Relative humidity and temperature of air are maintained according to current standards and documented."


During a tour of the hospital on 06/23/21 at 11:40 AM, Staff B showed the surveyor a patient care area described as the "Endoscopy Room". This area consisted of a "dirty" room for initial cleaning of endoscopes, a "clean" room for HLD and storage of endoscopes, and a room where the procedures are conducted. Staff B reported that during a previous survey, the facility was informed they did not have to maintain positive and negative ventilation or specific humidity levels in these areas because it's a "procedure room" and this was not done. The LSC surveyor requested documentation of temperature and relative humidity logs, as well as testing of positive/negative ventilation and air exchanges per hour of these areas. No documentation was provided.