HospitalInspections.org

THIS IS A RECITE

Based on interview and observation, the facility failed to maintain fire doors and fire wall separation between the OR Addition and the Mont Reid Pavilion. This has the potential to affect all 483 patients and their visitors.
Finding:
On 10/03/12 at 3:10 P.M. a tour was conducted of the second floor of the OR Addition Building with Staff HH and II. The tour revealed the floor to be sprinklered throughout and to contain an intensive care suite.
The tour revealed two sets of doors in the fire wall separating the OR Addition Building from the Mont Reid Pavilion were not fire rated doors.
The tour revealed the doors in the fire wall separating the OR Addition Building corridor (279) from the Mont Reid Pavilion also were not fire rated doors.
In an interview during the tour, Staff HH confirmed the findings.

Interview with Staff A1 took place the morning hours of 11/28/12. Staff A1 stated they had put in a purchase order for both sets of doors and they have not come in yet.

THIS IS A RECITE
Based on interview and observation, the facility failed to ensure each dutch door that opened onto a corridor was equipped with a latching device on both the upper and lower leaf, in accordance with NFPA 101, 19.3.6.3.6. This has the potential to affect all 443 patients and their visitors.
Findings:
On 10/02/12 at 2:00 P.M. the third floor was toured with Staff HH and II. The tour revealed the floor contained a neonatal intensive care unit consisting of a suite of multiple bassinets. The tour revealed a pharmacy with a door that opened onto corridor 3013. The door was a dutch door. The upper part of the dutch door was observed not to have a latching device.
On 10/02/12 at 2:00 P.M. in an interview Staff II confirmed the finding.
Interview with Staff A1 took place the morning hours of 11/28/12. Staff A1 stated they had put in a purchase order for a door and it has not come in yet.

THIS IS A RE-CITE

Based on observation and interview, the facility failed to maintain a suite of rooms for the neonatal intensive care unit on the third floor, the surgical intensive care unit on the second floor, and for the emergency department on the ground floor, to less than 5000 square feet according to National Fire Protection Association 101 Chapter 19.2.5.6. This has the potential to affect all 483 patients and their visitors.
Findings:
On 10/2/12 at 2:00 P.M. a tour was conducted of the third floor with Staff HH and II. The tour revealed the floor to contain a neonatal intensive care unit. The review revealed the floor to contain its bassinets throughout a suite. Review of the schematic revealed the area of the suite to be 16,728 square feet.
In an interview during the tour, Staff HH and II confirmed the nature of the bassinets distributed throughout the suite.
On 10/11/12 at 9:45 A.M. a tour was conducted of the second floor with Staff BB and Staff II. Review of the schematic and observation revealed the floor was used for surgical intensive care patients.
In an interview with Staff II and BB during the tour, they stated the suite of surgical intensive care beds was 8,893 square feet.
On 10/11/12 at 10:05 a tour was conducted of the ground floor of the building. The tour revealed the area was used for the treatment of emergency patients divided into three sections called Pod A, B, and D. These pods were observed to contain multiple curtained areas with patient beds within used for treatment.
In an interview with Staff II and BB during the tour, they stated the POD A, B, and D area comprised 10,166 square feet within the emergency room.

Interview with Staff A1 took place the morning hours of 11/28/12. Staff A1 stated they had applied for a waiver regarding the square footage of the suites.

THIS IS A RECITE
Based on review of humidity logs and interview, the facility failed to ensure the humidity levels in the operating rooms were maintained at or greater than 35 percent. This has the potential to affect all patients and family present for same day surgery.
Findings:
A review of the humidity logs for the building's operating room suites revealed humidity wasn't maintained at or above 35 percent. The review revealed 10/06/12 the humidity level was at 31 percent and on 10/11/12 the humidity was at 32percent.
On 10/11/12 at 2:30 P.M. in an interview Staff EE said operating room staff did not check humidity levels and there was a bad humidification sensor such that an alarm wasn't triggered when the level dropped to less than 35 percent. He/she said he/she didn't realize the sensor wasn't working until the surveyor checked the humidity levels. He/she said he/she just then discovered that the sensor was no longer part of the computerized program. He/she confirmed the operating rooms were in use with general anesthesia during the time the humidity levels were less than 35 percent.
Interview with staff A1 during the morning hours of 11/29/12 reveals the humidity sensor is still on order and they are waiting on delivery and instillation.