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AURORA ST LUKES MEDICAL CENTER
PHYSICAL ENVIRONMENT
Tag No.: A0700
An unannounced, onsite federally authorized survey was conducted at Aurora St. Luke's Medical Center in Milwaukee, WI from 5/4/2015 through 5/8/2015. A verification visit was conducted July 27-28, 2015.
Based on observation, interview and review of record documents the hospital failed to be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for hospital services appropriate to the needs of the community. These deficiencies occur in all of the 215 smoke compartments and would affect all inpatients, outpatients, staff, and visitors within these smoke compartments.
Findings include:
A-700: The facility failed to maintain a safe environment from fire based on the following eight (8) K-tags:
K-18 (corridor door openings);
K-27 (smoke barrier doors);
K-29 (hazardous spaces);
K-56 (installation of automatic sprinkler systems);
K-130 (miscellaneous means of egress findings);
K-147 (electrical wiring);
K-154 (sprinkler system fire watch); and
K-155 (fire alarm system fire watch).
Based on the cumulative effects of the above deficiencies, 42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET.
Please refer to the K-tags found later in this report for the specific findings.
LIFE SAFETY FROM FIRE
Tag No.: A0709
An unannounced, onsite federally authorized survey was conducted at Aurora St. Luke's Medical Center in Milwaukee, WI from 5/4/2015 through 5/8/2015. A verification visit was conducted July 27-28, 2015.
Based on observation, interview and review of record documents the hospital failed to be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for hospital services appropriate to the needs of the community. These deficiencies occur in all of the 215 smoke compartments and would affect all inpatients, outpatients, staff, and visitors within these smoke compartments.
Findings include:
A-700: The facility failed to maintain a safe environment from fire based on the following eight (8) K-tags:
K-18 (corridor door openings);
K-27 (smoke barrier doors);
K-29 (hazardous spaces);
K-56 (installation of automatic sprinkler systems);
K-130 (miscellaneous means of egress findings);
K-147 (electrical wiring);
K-154 (sprinkler system fire watch); and
K-155 (fire alarm system fire watch).
Based on the cumulative effects of the above deficiencies, 42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET.
Please refer to the K-tags found later in this report for the specific findings.