HospitalInspections.org

Based on observations, staff interview and/or documentation review as referenced in the Life Safety Report of survey completed on 01/24/2019, the hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

The findings include:

1. The facility failed to ensure all preventive maintance programs (mechanical, electrical, and patient-care equipment) are maintained in a safe operating manner.

~cross refer to 485.623(b)(1) - Maintenance Standard Tag C0222

2. The facility failed to ensure proper ventilation, lighting, and temperature control in all pharmaceutical, patient care, and food preparation areas.

~cross refer to 485.623(b)(5) - Maintenance Standard Tag C0226

3. The hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

~cross refer to 485.623(d)(1) & (3) - Life Safety from Fire Standard Tag C0231

4. The hospital failed to install alcohol-based hand rub dispensers in a manner that adequately protects against inappropriate access.
~cross refer to 485.623(c)(5) - Life Safety from Fire Standard Tag C0237

Based on observations, staff interview and/or documentation review and as referenced in the Life Safety Report of Survey completed January 24, 2019, the facility failed to ensure all preventive maintance programs (mechanical, electrical, and patient-care equipment) are maintained in a safe operating manner.

The findings include:

1. Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to 1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility inspection and records of the emergency power system was non-compliant the specific items include:

This Life Safety Code (LSC) validation survey was conducted January 23, 2019 at approximately 8:00 AM till January 24 approximately 12:00 PM utilizing the 2012 existing edition of the National Fire Protection Association (NFPA) 101 - Life Safety Code (LSC) and 2012 edition of the NFPA 99 - Health Care Facilities Code (HCFC) and its referenced publications. The facility plan/construction approval occurred prior to July 5, 2016. The facility plan/construction approval occurred prior to July 5, 2016. The facility is utilizing special locking systems. In the exit conference all LSC deficiencies noted were discussed and acknowledged with Administration.

Stories: One
Construction Type: I (322)
Constructed: 1979
Partially Sprinkled
At time of survey the Licensed bed capacity =57

Building 0104: Main Hospital

A. Record review of the facility's generator maintenance records for the 12 month period revealed the facility failed to have documentation showing monthly battery electrolyte / specific gravity checks values. Battery conductance testing shall be permitted in lieu of the testing of the specific gravity where applicable or warranted.

The facility did not have documentation from October and November of 2018.

Ref: 2012 NFPA 101 Sections 19.5.1; 9.1.2
2012 NFPA 99 Section 6.4.4.1
2010 NFPA 110, Sections 8.3.7*; 8.3.7.1

This deficiency affected the entire facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K0918

2. This Life Safety Code (LSC) validation survey was conducted January 23, 2019 at approximately 8:00 AM till January 24 approximately 12:00 PM utilizing the 2012 existing edition of the National Fire Protection Association (NFPA) 101 - Life Safety Code (LSC) and 2012 edition of the NFPA 99 - Health Care Facilities Code (HCFC) and its referenced publications. The facility plan/construction approval occurred prior to July 5, 2016. The facility plan/construction approval occurred prior to July 5, 2016. The facility is not utilizing special locking systems. In the exit conference all LSC deficiencies noted were discussed and acknowledged with Administration.

Stories: One
Construction Type: V (111)
Constructed: 2005
Non Sprinkled
At time of survey the Licensed bed capacity =57

Building 0204: Peachtree Athletic and Rehabilitation Center

A. Based on observations, staff interview, and/or documentation on January 24, 2019 at 9:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

The facility maintenance and inspection of emergency electrical system was non-compliant the specific items include:

The facility electrical closet/storage room located behind the main information desk has items stored in front of electrical panels. The facility must maintain sufficient access and working space for the electrical panels to permit ready and safe operation of the electrical equipment.

Ref: 2012 NFPA 101 Section 39.5.1; 9.1.2
2011 NFPA 70 Section 110-26

This deficiency affected the main electrical room at the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K0511

3. This Life Safety Code (LSC) validation survey was conducted January 23, 2019 at approximately 8:00 AM till January 24 approximately 12:00 PM utilizing the 2012 existing edition of the National Fire Protection Association (NFPA) 101 - Life Safety Code (LSC) and 2012 edition of the NFPA 99 - Health Care Facilities Code (HCFC) and its referenced publications. The facility plan/construction approval occurred prior to July 5, 2016. The facility plan/construction approval occurred prior to July 5, 2016. The facility is not utilizing special locking systems. In the exit conference all LSC deficiencies noted were discussed and acknowledged with Administration.

Stories: One
Construction Type: V (111)
Constructed: 2012
Non Sprinkled
At time of survey the Licensed bed capacity =57

Building 0304: Wound Care

A. Based on observations, staff interview, and/or documentation on January 24, 2019 at 9:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

The facility maintenance and inspection of emergency electrical system was non-compliant the specific items include:

The electrical closet/storage room located across from the nitrogen storage room has storage in front of the electrical panels The facility must maintain sufficient access and working space for the electrical panels to permit ready and safe operation of the electrical equipment.

Ref: 2012 NFPA 101 Sections 39.5.1; 9.1.2
2011 NFPA 70 Section 110-26

This deficiency affected the main electrical room at the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K0511

4. This Life Safety Code (LSC) validation survey was conducted January 23, 2019 at approximately 8:00 AM till January 24 approximately 12:00 PM utilizing the 2012 existing edition of the National Fire Protection Association (NFPA) 101 - Life Safety Code (LSC) and 2012 edition of the NFPA 99 - Health Care Facilities Code (HCFC) and its referenced publications. The facility plan/construction approval occurred prior to July 5, 2016. The facility plan/construction approval occurred prior to July 5, 2016. The facility is not utilizing special locking systems. In the exit conference all LSC deficiencies noted were discussed and acknowledged with Administration.

Stories: One
Construction Type: V (111)
Constructed: 2016
Non Sprinkled
At time of survey the Licensed bed capacity =57

Building 0404: Urology

A. Based on observations, staff interview, and/or documentation on January 24, 2019 at 9:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

The facility maintenance and inspection of emergency electrical system was non-compliant the specific items include:

The outside electrical / mechanical room has storage in front of the electrical panels. The facility must maintain sufficient access and working space for the electrical panels to permit ready and safe operation of the electrical equipment.

Ref: 2012 NFPA 101 Sections 39.5.1; 9.1.2
2011 NFPA 70 Section 110-26

This deficiency affected the main electrical room at the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~cross refer to Life Safety Code Standard - NFPA 101, Tag K0511

Based on observations, staff interview and/or documentation review as referenced in the Life Safety Report of Survey completed January 24, 2019, the facility failed to ensure proper ventilation, lighting, and temperature control in all pharmaceutical, patient care, and food preparation areas.

The findings include:

1. This Life Safety Code (LSC) validation survey was conducted January 23, 2019 at approximately 8:00 AM till January 24 approximately 12:00 PM utilizing the 2012 existing edition of the National Fire Protection Association (NFPA) 101 - Life Safety Code (LSC) and 2012 edition of the NFPA 99 - Health Care Facilities Code (HCFC) and its referenced publications. The facility plan/construction approval occurred prior to July 5, 2016. The facility plan/construction approval occurred prior to July 5, 2016. The facility is utilizing special locking systems. In the exit conference all LSC deficiencies noted were discussed and acknowledged with Administration.

Stories: One
Construction Type: I (322)
Constructed: 1979
Partially Sprinkled
At time of survey the Licensed bed capacity =57

Building 0104: Main Hospital

A. Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to 1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility inspection of the duct detectors in the attic space above the procedure center was non-compliant the specific items include:

The facility has smoke duct detectors in the attic space that do not have an access door installed to visually inspect the sampling tubs to ensure that there are no changes in the system that effect the performance of the equipment.

Ref: 2012 NFPA 101 Sections 19.5.2.1; 9.2
2010 NFPA 72 Section 14.4.2.2*

This deficiency affected one of two smoke zones in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

The facility maintenance and inspection of Heating Ventilation and Air Conditioning System (HVAC) systems was non-compliant the specific items include:

1. The facility laundry department has two fire dampers installed in the one hour fire rated barrier on the main corridor. These dampers are not equipped with access doors in order to allow for inspection and testing as required.

Ref: 2012 NFPA 101 Section 19.5.2.1
2012 NFPA 90A Section 4.3.5.1

This deficiency affected two smoke compartments.

2. The smoke duct detector sampling tubes located in the Pharmacy department was not maintained clean and in good condition. The duct detector sampling tubes are not installed properly as required.

Ref: 2012 NFPA 101 Section 19.5.2.1; 9.2
2012 NFPA 90A Section 6.4.4.1
2010 NFPA 72 Section 14.4.2.2

This deficiency affected one smoke compartments.

3. The facility air handler shut down sequence did not stop the entire air flow at the return air registers at (a) Same Day Surgery, (b) Cardiopulmonary

Ref: 2012 NFPA 101 Section 19.5.2.1; 9.2
2012 NFPA 90A Section 4.2.4.1.1
2010 NFPA 72 Section 14.1.2

This deficiency affected two smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to Life Safety Code Standard- NFPA 101, Tag K0521

Based on observations, staff interview and/or documentation review as referenced in the Life Safety Report of Survey completed January 24, 2019, the hospital failed ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

The findings include:

1. This Life Safety Code (LSC) validation survey was conducted January 23, 2019 at approximately 8:00 AM till January 24 approximately 12:00 PM utilizing the 2012 existing edition of the National Fire Protection Association (NFPA) 101 - Life Safety Code (LSC) and 2012 edition of the NFPA 99 - Health Care Facilities Code (HCFC) and its referenced publications. The facility plan/construction approval occurred prior to July 5, 2016. The facility plan/construction approval occurred prior to July 5, 2016. The facility is utilizing special locking systems. In the exit conference all LSC deficiencies noted were discussed and acknowledged with Administration.

Stories: One
Construction Type: I (322)
Constructed: 1979
Partially Sprinkled
At time of survey the Licensed bed capacity =57

Building 0104: Main Hospital

A. Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to 1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility inspection of exiting from interior rooms to the egress corridor was non-compliant the specific items include:

The corridor door to the Pharmacy is equipped with a dead bolt that required more than one motion of the hand to exit the room when the device is locked. Releasing mechanism shall open the door leaf with not more than one releasing operation, unless otherwise specified. Doors shall be arraigned to be opened readily from the egress side whenever the building is occupied.

Ref: 2012 NFPA 101 Sections 19.2.1; 7.2.1.5.1; 7.2.1.5.10.3, 7.2.1.10.4, 7.2.1.5.10.6.

This deficiency affected one smoke zone in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to Life Safety Code Standard- NFPA 101, Tag K0211

B. Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to 1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility inspection and maintenance of suite separation was non-compliant the specific items include:

1. The corridor doors to the intensive care suite (3155 sq. ft. in size) has a set of double doors that open onto the corridor and are not equipped with positive latching hardware as required.

2. The corridor doors to the emergency department suite (6799 sq. ft. in size) located next to room 2-3 has a set of double doors that open onto the corridor and are not equipped with positive latching hardware as required.

3. One of two corridor doors to the emergency department suite (6799 sq. ft. in size) located next to break room has one of two doors that open onto the corridor where the positive latching hardware does not operate as required.

Ref: NFPA 101 Sections 19.2.5.7.1.2 (1); 19.3.6.3.5

1. The smoke partition located in the OR in the wall above the ceiling tile in the break room and woman's locker room was not sealed as required.

2. The smoke partition in the Medical Surgical unit above the ceiling at the bathroom wall has three hole that were not sealed as required.

Ref: NFPA 101 Section 19.2.5.7.1.2

3. The smoke partition above the door to the labor and delivery suite was not sealed as required to limit the passage of smoke at that location.

Ref: 2012 NFPA 101 19.2.5.7.1.2

These deficiencies affected four smoke zones in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to Life Safety Code Standard- NFPA 101, Tag K0255

C. Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to 1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility inspection of hazardous areas was non-compliant the specific items include:

The facility has unsealed penetrations in the rated ceiling in the main laundry department above the gas fired dryers where the exhaust duct penetrates the rated ceiling. The laundry department has gas fired dryers installed and is greater than 100 square feet in size.

Ref: 2012 NFPA 101 Sections 19.3.2.1; 8.7.1; 8.3.1.1

This deficiency affected one smoke zone in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to Life Safety Code Standard- NFPA 101, Tag K0321

D. Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to 1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility inspection and maintenance of the fire alarm system components was non-compliant the specific items include:

During the inspection and testing of the facility fire alarm system that consisted of multiple components the automatic dialer component was tested. During this test the phone line communicator for the Fire Alarm Control Panel (FACP) was disconnected. The audible alert was not in a regularly manned area of the hospital.

Ref: 2012 NFPA 101 Sections 19.3.4; 9.6; 9.7.5
2010 NFPA 72 Section 26.6.3.2

This deficiency affected the entire facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to Life Safety Code Standard- NFPA 101, Tag K0345

E. Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility inspection of areas requiring sprinkler coverage was non-compliant the specific items include:

The facility has paper backed insulation in the interstitial space above the ceiling tiles in the follow areas:

1. Purchasing department's storage room.
2. The service corridor bathrooms.

Concealed spaces filled with noncombustible insulation shall not require sprinkler protection. The paper backed insulation at the above mentioned areas are combustible and require sprinkler protection.

Ref: 2012 NFPA 101 Sections 19.3.5.1; 9.7.2.1
2010 NFPA 13 Section 8.15.1.2.7

This deficiency affected one smoke zone in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to Life Safety Code Standard- NFPA 101, Tag K0351

F. Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility inspection and testing of supervisory signals to the fire alarm control panel was non-compliant the specific items include:

The supervisory signal for the electronically supervised tamper alarm on the sprinkler control valve at the Fire Alarm Control Panel (FACP) could be silenced permanently when the valve was in the closed position in the sprinkler riser room. Supervisory signals shall not be silenced permanently except by reopening/restoration of the valve to the normal operating position.

Where supervised automatic sprinkler systems are required by another section of this code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed at a location within the protected building that is constantly attended by qualified personnel.

Ref: 2012 NFPA 101 Sections 19.3.5.1; 9.7.2.1
2012 NFPA 72 Section 14.1.1

This deficiency affected the entire facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to Life Safety Code Standard- NFPA 101, Tag K0352

G. Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility inspection of area that are open to the egress corridor was non-compliant the specific items include:

The Gift Shop is open to the corridor and is not equipped with sprinkler protection. This smoke zone in the facility is not covered by an approved automatic sprinkler system. If the gift shop is less than 500 sq. ft. the Gift Shop may remain open to the corridor provided that the one of the following criteria is met:

(a) The building is protected throughout by an approved automatic sprinkler system in accordance with section NFPA 101: 9.7.

(b) the gift shop is protected throughout by an approved automatic sprinkler system in accordance with section NFPA 101: 9.7 and storage is separately protected.

Ref: 2012 NFPA 101 Section 19.3.6.1(4)

This deficiency affected one smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to Life Safety Code Standard- NFPA 101, Tag K0361

H. Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to 1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility inspection of smoke barrier wall areas was non-compliant the specific items include:

The facility has unsealed penetrations in the rated smoke barrier walls at the following locations:

1. The kitchen above the ceiling tile at the door connecting the nursing home dining room to the kitchen.
2. The waiting room of the intensive care unit.

Ref: 2012 NFPA 101 Sections 19.1.6.1; 8.3.5.6.1; 8.5.1

This deficiency affected two smoke zone in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to Life Safety Code Standard- NFPA 101, Tag K0372

I. Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility maintenance and inspection of areas soiled linen was stored was non-compliant the specific items include:
The facility has soiled linen and a trash containers of combustible materials located outside the ambulance entrance under the canopy overhang greater than 4 feet to the emergency department. The containers are left unattended under a canopy that is not protected with sprinkler coverage as required.

Ref: 2012 NFPA 101 Section 19.7.5.7.1 (3)

Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity and shall meet all of the following requirements:

(1) The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2).
(2) A capacity of 32 gal (121 L) shall not be exceeded within any 64 ft2 (6 m2) area.
(3)*Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.
(4) Container size and density shall not be limited in hazardous areas.

This deficiency affected one smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to smoke and or fire.

~ cross refer to Life Safety Code Standard- NFPA 101, Tag K0754

J. Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility maintenance and inspection of protection at the bulk oxygen area was non-compliant the specific items include:

The facility does not have noticeable bulk oxygen tank area protection from vehicular damage. The area does not have stop protection for the vehicle that fills the bulk oxygen tank.

Ref: 2012 NFPA 101 Section 19.3.2.4
2012 NFPA 99 Section 5.1.3.3.1 (4)
2010 NFPA 55 Section 4.11

This deficiency affected the main bulk oxygen storage area.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to Life Safety Code Standard- NFPA 101, Tag K0923

2. This Life Safety Code (LSC) validation survey was conducted January 23, 2019 at approximately 8:00 AM till January 24 approximately 12:00 PM utilizing the 2012 existing edition of the National Fire Protection Association (NFPA) 101 - Life Safety Code (LSC) and 2012 edition of the NFPA 99 - Health Care Facilities Code (HCFC) and its referenced publications. The facility plan/construction approval occurred prior to July 5, 2016. The facility plan/construction approval occurred prior to July 5, 2016. The facility is not utilizing special locking systems. In the exit conference all LSC deficiencies noted were discussed and acknowledged with Administration.

Stories: One
Construction Type: V (111)
Constructed: 2005
Non Sprinkled
At time of survey the Licensed bed capacity =57

Building 0204: Peachtree Athletic and Rehabilitation Center

A. Based on observations, staff interview, and/or documentation on January 24, 2019 at 9:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

The facility inspection and maintenance of the exit discharge was non-compliant the specific items include:

The facility did not provide a solid walking surface other than grass or soil from the required exit from the rear area of the facility leading to the public way. Required exit shall allow a level walking surface terminating directly at a public way.

Ref: 2012 NFPA 101 Sections 39.2.1.1; 7.7.1*

This deficiency affected one of two required exits from the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to Life Safety Code Standard- NFPA 101, Tag K0211

3. This Life Safety Code (LSC) validation survey was conducted January 23, 2019 at approximately 8:00 AM till January 24 approximately 12:00 PM utilizing the 2012 existing edition of the National Fire Protection Association (NFPA) 101 - Life Safety Code (LSC) and 2012 edition of the NFPA 99 - Health Care Facilities Code (HCFC) and its referenced publications. The facility plan/construction approval occurred prior to July 5, 2016. The facility plan/construction approval occurred prior to July 5, 2016. The facility is not utilizing special locking systems. In the exit conference all LSC deficiencies noted were discussed and acknowledged with Administration.

Stories: One
Construction Type: V (111)
Constructed: 2012
Non Sprinkled
At time of survey the Licensed bed capacity =57

Building 0304: Wound Care

A. Based on observations, staff interview, and/or documentation on January 24, 2019 at 9:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

The facility inspection and maintenance of the exit discharge was non-compliant the specific items include:

The means of egress from the back exit discharge to the public way was not maintained in good condition. There was tree limbs and branches that were cut and laying across the sidewalk. The sidewalk was not maintained clear of all obstructions

Ref: 2012 NFPA 101 Sections 39.2.1.1; 7.1.10.1

This deficiency affected one of two required exits from the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to Life Safety Code Standard- NFPA 101, Tag K0211

B. Based on observations, staff interview, and/or documentation on January 24, 2019 at 9:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

The facility maintenance and inspection storage area doors was non-compliant the specific items include:

The facility storage room with liquid nitrogen storage and supplies was not equipped with a self-closing device. This room has combustible materials storied inside and is greater than 50 square feet. Doors in barriers required to have a fire resistance rating shall have a minimum 3/4 hour protection rating and shall be self-closing or automatic-closing.

Ref: 2012 NFPA 101 Sections 39.3.2.1; 8.7.1.3; 7.2.1.8

This deficiency affected one of two storage rooms in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to Life Safety Code Standard- NFPA 101, Tag K0321

C. Based on observations, staff interview, and/or documentation on January 24, 2019 at 9:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

The facility maintenance and inspection of information signs at the bulk oxygen area was non-compliant the specific items include:

The facility does not have noticeable signs at the bulk oxygen fencing noting that smoking is prohibited. This signage must be prominently and strategically placed to alert the public that this area does not allow smoking.

Ref: 2012 NFPA 101 Section 19.3.2.4
2012 NFPA 99 Section 11.5.3.2.3

This deficiency affected the main bulk oxygen storage fencing.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to Life Safety Code Standard- NFPA 101, Tag K0928

4. This Life Safety Code (LSC) validation survey was conducted January 23, 2019 at approximately 8:00 AM till January 24 approximately 12:00 PM utilizing the 2012 existing edition of the National Fire Protection Association (NFPA) 101 - Life Safety Code (LSC) and 2012 edition of the NFPA 99 - Health Care Facilities Code (HCFC) and its referenced publications. The facility plan/construction approval occurred prior to July 5, 2016. The facility plan/construction approval occurred prior to July 5, 2016. The facility is not utilizing special locking systems. In the exit conference all LSC deficiencies noted were discussed and acknowledged with Administration.

Stories: One
Construction Type: V (111)
Constructed: 2016
Non Sprinkled
At time of survey the Licensed bed capacity =57

Building 0404: Urology

A. Based on observations, staff interview, and/or documentation on January 24, 2019 at 9:00 AM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

The facility maintenance and inspection storage area doors was non-compliant the specific items include:

The facility storage room across from the doctor's office was not equipped with a self-closing device. This room has combustible materials storied inside and is greater than 50 square feet. Doors in barriers required to have a fire resistance rating shall have a minimum 3/4 hour protection rating and shall be self-closing or automatic-closing.

Ref: 2012 NFPA 101 Sections 39.3.2.1; 8.7.1.3; 7.2.1.8

This deficiency affected one of two storage rooms in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to Life Safety Code Standard- NFPA 101, Tag K0321

Based on observations, staff interview and/or documentation review as referenced in the Life Safety Report of Survey completed January 24, 2019, the facility failed to install alcohol-based hand rub dispensers in its facility if the dispensers are installed in a manner that adequately protects against inappropriate access.

The findings include:

1. This Life Safety Code (LSC) validation survey was conducted January 23, 2019 at approximately 8:00 AM till January 24 approximately 12:00 PM utilizing the 2012 existing edition of the National Fire Protection Association (NFPA) 101 - Life Safety Code (LSC) and 2012 edition of the NFPA 99 - Health Care Facilities Code (HCFC) and its referenced publications. The facility plan/construction approval occurred prior to July 5, 2016. The facility plan/construction approval occurred prior to July 5, 2016. The facility is utilizing special locking systems. In the exit conference all LSC deficiencies noted were discussed and acknowledged with Administration.

Stories: One
Construction Type: I (322)
Constructed: 1979
Partially Sprinkled
At time of survey the Licensed bed capacity =57

Building 0104: Main Hospital

A. Based on observations, staff interview and/or documentation review on 1/23/2019, at approximately 8:00 AM to 1/24/2019 approximately 12:00 PM, the following deficiencies were noted:

The facility inspection of locations of Alcohol Based Hand Rub Dispenser (ABHR) was non-compliant the specific items include:

The facility has soap dispensers installed above electrical receptacles on the patient care wings of the hospital. The soap in these dispensers have a concentration of alcohol within them that the soap is considered flammable.

Ref: 2012 NFPA 101 Sections 19.3.2.6 (8)

This deficiency affected two smoke zones in the facility.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to Life Safety Code Standard- NFPA 101, Tag K0325

Based on hospital policy review, medical record form review, observations, and staff interview, the hospital staff failed to maintain the confidentiality of record information and provide safeguards against unauthorized use for 6 of 15 observations of patient-specific information posted outside of the patient's room during tours of the Medical/Surgical unit (100 and 200 halls).

The findings include:

Review of hospital policy #4349451 "Patient and Family Rights and Responsibilities review/revised date: 03/2018, Notification of Rights and Responsibilities ...(Named facility) will inform through *Informational brochure, detailing rights and responsibilities of care. ... The brochures and other means as determined by the facility will be provided in format understandable to the patient or representative, thereby allowing the patient adequate exercise of their rights and responsibilities. ...The Brochure will be provided at the time of registration ... Statement of Rights * ...The right to every consideration of his privacy concerning his own medical program. Case discussion, consultation, examination and treatment are considered confidential and shall be conducted discreetly *The right to have all records pertaining to his medical care treated as confidential except as otherwise provided by law or third party contractual arrangements ..."

Review of a medical record form, "Patient/Resident Directory Instructions", provided to each patient as part of the admission process, revealed, "I DO___DO NOT___want my name included as part of the "Named Facility" patient/Resident Directory. I understand that if I do not consent to this disclosure, visitors such as family and friends, outside phone callers, and delivery people, may not be able to contact me. I understand that by consenting to be a part of the Patient/Resident Directory my presence, location and general condition shall be released for those individuals that ask for me by name. I DO___DO NOT___want my name posted outside my door. I DO___DO NOT___ consent to the disclosure of my religious affiliation to members of the clergy. I understand that if I do not consent to this disclosure, members of the clergy, who do not know to ask for me by name, may not be able to contact me. I give consent to the disclosure of my Protected Health Information needed by the following family members and/or close personal friends who may be involved in my care.
(ENTER NAMES)______________."


40299

1. Observation on 01/23/2019 at 0930 during facility tour on the Medical-Surgical unit (200 hallway) revealed the patient's full name was posted outside the door to their room and white boards outside of patient rooms with active medical treatment information written on the boards related to individual patient care regimens. Observation of a white board outside of room 209 (Patient #31) revealed a full patient name, and the following ordered services: "Tele (Telemetry, remote cardiac monitoring), Strict I/O (intake/output), Q2turn (turn every 2 hours), Daily wgt (weight), Tube Feeding (schedule with administration times listed) BM with a date (date of last bowel movement), and Bath with a date (date of last bath)."

Interview during tour on 01/23/2019 at 0930 with RN #2 revealed the white boards were used to help staff with patient care. Interview revealed the "Bath" with a date beside it meant the date the patient had a bath, "BM" with a date was the last time the patient had a bowel movement.

2. Observation on 01/23/2019 at 0930 during tour in the hallway outside room 216 (Patient #9) revealed "Bath" with a date (date of last bath) was listed on the white board.

Interview during tour on 01/23/2019 at 0930 with RN #2 revealed the white boards were used to help staff with patient care. Interview revealed the "Bath" with a date beside it meant the date the patient had a bath.


35306

3. Observation on 01/23/2019 at 0930 during tour of the Medical/Surgical unit (100 hallway) revealed, the patient's first and last name appeared on a name plate, beside the door, outside room #101 (Patient #7). Observation revealed a white dry-erase board located directly beside the patient's name with the following information hand-written on the board: "Dysphagia 1 (diet); honey-level liquids; feeding assistance; Q2h (turn); B=1/22."

Interview on 01/23/2019 at 0930 with RN #3 and RN #4 revealed there were currently 15 inpatients on the Medical/Surgical unit and that the patient's first and last names were posted outside each patient's room, throughout the hospital, if permission had been granted via the "Patient/ Resident Directory Instructions" form completed on admission. During the interview, RN #4 indicated that it was not known whether the patient was asked if both the first and last name could be posted outside the room on admission and that patients were not aware of the specific information staff write on the dry-erase boards. RN #4 shared the white dry-erase boards were used as a means of "communication" for staff. In review of the information on the white dry-erase board outside room 101, RN #3 indicated the patient had difficulty swallowing and required assistance with meals, thus the Dysphagia, honey-level liquid diet, required every two hour turning to prevent skin break down and that his last bowel movement (B) was "1/22". Continued interview revealed the information was patient specific and considered part of the individualized plan of care.

4. Observation on 01/23/2019 at 0935 revealed, the patient's first and last name appeared on a name plate, beside the door, outside room #104 (Patient #32). Observation revealed a "communication" board located directly beside the patient's name with the diet hand written on the board.

Interview at approximately 0935 with RN #4 revealed the information on the communication board was patient specific and considered part of the individualized plan of care.

5. Observation on 01/23/2019 at 0940 revealed the patient's first and last name on a name plate outside room #107 (Patient #8). Observation revealed a white dry-erase board directly beside the patient's name with the following patient-specific information hand-written on the board, "Q2h (turn), 2-person assist". In review of the information on the "communication" board outside the patient's room during the observation, RN #3 indicated the patient required a 2-person assist with ambulation and was to be turned every 2 hours to prevent skin break down.

Interview at approximately 0940 with RN #4 revealed the information on the communication board was patient specific and considered part of the individualized plan of care. During the interview, both RN #3 and #4 revealed information on the white dry-erase boards had not historically been viewed as "protected" but that looking at it during the tour, now viewed it differently. Interview revealed protected, patient-specific information was available for anyone to see.

6. Observation on 01/23/2019 at 0955 revealed the patient's first and last name on a name plate outside room #217(Patient #33). Observation revealed a "communication" board directly beside the patient's name with "BM:" handwritten on the board with no date. In review of the information on the "communication" board outside the patient's room during the observation, RN #4 indicated staff document the date of the patient's last bowel movement on the communication boards for tracking purposes.

Interview on 01/23/2019 at 1000 with the Patient #33 revealed he was not aware that his first and last name, specifically, was posted outside his door but was ok with it being there. Interview revealed the patient was not aware that patient-specific information was written on the dry-erase board outside his room.