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Based on observations during tour of facility buildings, review of facility inspection records, testing, and staff interviews, it was determined that the governing body failed to ensure that the facility's maintenance and construction programs functioned in a manner to properly maintain the facility's buildings.

Findings were:

Cross-refer to A700 as it relates to failure of the facility to ensure that the hospital was constructed, arranged, and maintained to ensure the safety of patients and staff.

Based on observations tour of facility buildings, review of facility inspection records, testing, and staff interviews, it was determined that the facility failed to ensure that the hospital was constructed, arranged, and maintained to ensure the safety of patients and staff.

Findings were:

Building 1 - Main Building:

Cross-refer to Life Safety Code deficiency K018 as it relates to failure of the facility to ensure that all doors closed and latched properly;

Cross-refer to Life Safety Code deficiency K020 as it relates to failure of the facility to ensure that all vertical openings were properly protected;

Cross-refer to Life Safety Code deficiency K025 as it relates to failure of the facility to ensure that all smoke barrier walls provided a one-half hour fire resistance rating;

Cross-refer to Life Safety Code deficiency K027 as it relates to failure of the facility to ensure that all smoke barrier doors properly closed;

Cross-refer to Life Safety Code deficiency K029 as it relates to failure of the facility to ensure that all fire doors properly closed and latched with penetrations sealed;

Cross-refer to Life Safety Code deficiency K034 as it relates to failure of the facility to ensure that stairwell guardrails were at the proper height and properly spaced;

Cross-refer to Life Safety Code deficiency K050 as it relates to failure of the facility to ensure that fire drills were held at unexpected times and under varying conditions;

Cross-refer to Life Safety Code deficiency K052 as it relates to failure of the facility to ensure that smoke detectors were properly installed and that the fire alarm system was properly tested and maintained;

Cross-refer to Life Safety Code deficiency K062 as it relates to failure of the facility to ensure that the sprinkler system was properly installed and maintained;

Cross-refer to Life Safety Code deficiency K064 as it relates to failure of the facility to ensure that accurate records for portable fire extinguishers were maintained; and

Cross-refer to Life Safety Code deficiency K147 as it relates to failure of the facility to ensure that electrical equipment was maintained of of the correct type.


Building 2 - W. T. Anderson Health Center:

Cross-refer to Life Safety Code deficiency K034 as it relates to failure of the facility to ensure that stairwell guardrails were at the proper height and properly spaced;

Cross-refer to Life Safety Code deficiency K046 as it relates to failure of the facility to ensure that emergency lighting was provided at exits;

Cross-refer to Life Safety Code deficiency K047 as it relates to failure of the facility to ensure that all exit signs were illuminated; and

Cross-refer to Life Safety Code deficiency K054 as it relates to failure of the facility to ensure that smoke detectors were properly installed.


Building 3 - Women's Ambulatory Health:

Cross-refer to Life Safety Code deficiency K054 as it relates to failure of the facility to ensure that smoke detectors were properly installed.


Building 4 - Center for Ambulatory Surgery:

Cross-refer to Life Safety Code deficiency K020 as it relates to failure of the facility to ensure that penetrations in the stairwell was properly protected;

Cross-refer to Life Safety Code deficiency K025 as it relates to failure of the facility to ensure that all smoke barrier walls provided a one-half hour fire resistance rating;

Cross-refer to Life Safety Code deficiency K027 as it relates to failure of the facility to ensure that all smoke barrier doors provided the proper protection;

Cross-refer to Life Safety Code deficiency K029 as it relates to failure of the facility to ensure that all fire doors properly closed and latched;

Cross-refer to Life Safety Code deficiency K038 as it relates to failure of the facility to ensure that exits were accessible at all times;

Cross-refer to Life Safety Code deficiency K046 as it relates to failure of the facility to ensure that emergency lighting was provided at all outside exits;

Cross-refer to Life Safety Code deficiency K054 as it relates to failure of the facility to ensure that smoke detectors were properly installed; and

Cross-refer to Life Safety Code deficiency K062 as it relates to failure of the facility to ensure that the pressure gauges for the sprinkler system were properly tested.


Building 5 - The Children's Hospital:

Cross-refer to Life Safety Code deficiency K017 as it relates to failure of the facility to ensure that corridor walls were properly sealed to prevent the transfer of smoke;

Cross-refer to Life Safety Code deficiency K018 as it relates to failure of the facility to ensure that all doors closed and latched properly;

Cross-refer to Life Safety Code deficiency K020 as it relates to failure of the facility to ensure that vertical openings were properly protected and sealed;

Cross-refer to Life Safety Code deficiency K025 as it relates to failure of the facility to ensure that all smoke barriers were properly sealed and protected;

Cross-refer to Life Safety Code deficiency K029 as it relates to failure of the facility to ensure that hazardous area fire doors were of the proper type and properly closed and latched;

Cross-refer to Life Safety Code deficiency K034 as it relates to failure of the facility to ensure that stairwell guardrails were at the proper height and properly spaced;

Cross-refer to Life Safety Code deficiency K046 as it relates to failure of the facility to ensure that emergency lighting was provided at all exits;

Cross-refer to Life Safety Code deficiency K054 as it relates to failure of the facility to ensure that smoke detectors were properly installed;

Cross-refer to Life Safety Code deficiency K064 as it relates to failure of the facility to ensure that portable fire extinguishers were properly mounted;

Cross-refer to Life Safety Code deficiency K067 as it relates to failure of the facility to ensure that the ground floor Patient Access office was provided with a HVAC return duct system; and

Cross-refer to Life Safety Code deficiency K069 as it relates to failure of the facility to ensure that combustible materials were not adjacent to the kitchen's range hood.


Building 6 - Crescent House:

Cross-refer to Life Safety Code deficiency K046 as it relates to failure of the facility to ensure that emergency lighting was provided at all exits.


Building 7 - Central Georgia Diagnostics PET:

Cross-refer to Life Safety Code deficiency K051 as it relates to failure of the facility to ensure that a fire alarm pull station was located near the main entrance and that smoke detectors were properly installed; and

Cross-refer to Life Safety Code deficiency K141 as it relates to failure of the facility to ensure that the medical gas storage room were provided with non-smoking and no smoking signs.


Building 8 - Medical Center East:

Cross-refer to Life Safety Code deficiency K038 as it relates to failure of the facility to ensure that the exit ramp at the main entrance was provided with handrails on both sides;

Cross-refer to Life Safety Code deficiency K046 as it relates to failure of the facility to ensure that emergency lighting was provided at exits and that emergency lighting units in corridors worked properly; and

Cross-refer to Life Safety Code deficiency K047 as it relates to failure of the facility to ensure that all exit and directional signs were illuminated.


Building 9 - Neighborhood Healthcare Center East: Closed


Building 10 - Central Georgia Hyperbaric Medicine:

Cross-refer to Life Safety Code deficiency K029 as it relates to failure of the facility to ensure that all fire walls were properly sealed and that fire doors properly closed and latched;

Cross-refer to Life Safety Code deficiency K077 as it relates to failure of the facility to ensure that the medical gas bulk storage area was provided with a fire extinguisher and that non-smoking and no smoking signs were provided; and

Cross-refer to Life Safety Code deficiency K141 as it relates to failure of the facility to ensure that the Hyperbaric Treatment Area was provided with non-smoking and no smoking signs on the outside of the area.


Building 11 - Luce Heart Institute:

Cross-refer to Life Safety Code deficiency K029 as it relates to failure of the facility to ensure that hazardous areas were properly sealed and that corridors were unobstructed;

Cross-refer to Life Safety Code deficiency K054 as it relates to failure of the facility to ensure that smoke detectors were properly installed;

Cross-refer to Life Safety Code deficiency K071 as it relates to failure of the facility to ensure that the linen chute's fire damper remained unblocked; and

Cross-refer to Life Safety Code deficiency K076 as it relates to failure of the facility to ensure that full and empty medical gas cylinders were stored separately in properly identified areas.


Building 12 - Medical Center North:

Cross-refer to Life Safety Code deficiency K038 as it relates to failure of the facility to ensure that exit ramps were provided with handrails on both sides; and

Cross-refer to Life Safety Code deficiency K054 as it relates to failure of the facility to ensure that smoke detectors were properly installed.


Building 13 - Medical Center Northwest:

Cross-refer to Life Safety Code deficiency K046 as it relates to failure of the facility to ensure that emergency lighting was provided in treatment/exam areas and at all exits; and

Cross-refer to Life Safety Code deficiency K047 as it relates to failure of the facility to ensure that exit signs were illuminated.


Building 14 - Family Health Center:

Cross-refer to Life Safety Code deficiency K051 as it relates to failure of the facility to address a trouble signal on the fire alarm panel.


Building 15 - Children's Health Center:

Cross-refer to Life Safety Code deficiency K034 as it relates to failure of the facility to ensure that stairwell guardrails were at the proper height and properly spaced;

Cross-refer to Life Safety Code deficiency K046 as it relates to failure of the facility to ensure that emergency lighting was provided in all areas; and

Cross-refer to Life Safety Code deficiency K076 as it relates to failure of the facility to ensure that the medical gas storage closet was not provided with a powered vent to the outside and was not properly marked with non-smoking and no smoking signs.