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Based on review of policies and procedures, review of temperature and humidity logs and interview, it was determined the facility failed to monitor the temperature and humidity levels in the Cystoscopy Room. The failed practice did not assure temperature and humidity levels were within a range which did not promote bacterial growth or compromise the integrity of sterile instruments and supplies. This failed practice had the potential to affect all persons undergoing cystoscopic procedures in the facility. Findings follow:

A. Review of temperature and humidity logs did not have evidence the Cystoscopy Room was monitored for acceptable ranges in temperature and humidity.

B. Review of policy, "Environmental Factors" revealed keep humidity in the Operating Rooms at 30-60% and maintain temperatures in the Operating Rooms between 68 - 73 degrees to reduce microbial growth.

C. During interview with the Director of Quality on 08/08/13 at 1045, he verified that humidity and temperature were not monitored in the Cystoscopy Room.

Based on review of operative reports and interview, it was determined 6 (#4, #6-#10) of 10 operative reports were not immediately signed. The failed practice did not assure the physician agreed with and authenticated the information transcribed in the operative report in a timely manner and had the potential to affect all patients undergoing surgery in the facility. Findings follow:

A. Review of the operative reports for Patients #4 and #6 revealed the procedures were performed on 07/17/13 and the physician authenticated the reports 15 days later on 07/31/13.

B. Review of the operative reports for Patients #7-#10 revealed the procedures were performed on 07/31/13 and the physician authenticated the reports seven days later on 08/07/13.

C. Findings were confirmed with the Director of Peri-Operative Services on 08/09/13 at 1100.