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Based on observation, interview, and record review, the facility failed to ensure the life safety code (LSC) requirements were met at the main campus and multiple hospital offsite locations. (A709) The findings have the potential to affect all 463 patients in the facility.

Based on observation, interview, and record review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all 463 patients at the facility.

Findings include:

K131 failed to maintain the two hour rated fire walls, failed to maintain a two hour building separation
K161 failed to maintain the construction classification for the building, failed to maintain the fire resistance rating of the type of construction
K211 failed to maintain a clear path of egress, failed to provide two means of egress
K222 failed to maintain delayed egress
K225 failed to provide exit stair enclosures, failed to maintain code compliant exits during construction
K291 failed to provide functional emergency lighting, failed to conduct an annual inspection of emergency and exit lights, failed to test battery powered emergency lights
K311 failed to ensure fire dampers were exercised every four years, failed to ensure vertical openings were properly enclosed
K321 failed to provide self closing doors for the protection of hazardous rooms, failed to provide protection from hazardous areas
K345 failed to ensure fire alarm system components were tested and maintained, failed to ensure sensitivity testing of smoke alarms, failed to provide a means of egress
K351 failed to install a sprinkler system in accordance with the NFPA requirements
K353 failed to ensure sprinklers and sprinkler system was properly maintained, failed to keep a sprinkler wrench with spare sprinklers
K355 failed to ensure portable fire extinguishers were inspected and maintained
K363 failed to have automatic positive latching corridor doors
K372 failed to ensure that smoke barrier walls were maintained, vertical openings complied with NFPA 101
K374 failed to maintain smoke barrier doors
K521 failed to ensure that a corridor was not used as a plenum
K929 failed to store oxygen cylinders in accordance with NFPA 101 requirements

Based on observations, staff interview, and review of facility policies the Infection Control Practitioner/Officer (ICPO) failed to ensure staff followed policy and procedures to prevent the potential spread of infection in one of three outpatient locations. This finding had the potential to increase the risk of infections for all patients admitted to the facility's outpatient service. The hospital census was 463 patients.

Findings include:

Review of the facility's undated policy titled "Cleaning of the Healthcare Facility" provided the following information:
" ...All employees are responsible for the cleanliness of their areas ...10. If a mattress or cart cover is found to be cracked, torn, or the vinyl surface is broken, it will be replaced ..."

Review of the facility's undated policy titled "Cleaning and Disinfection of Re-Usable Patient Care Equipment," provided the following information:
" ...F ...3. All exam tables, exercise equipment, and other patient equipment, should be cleaned or low level disinfected between each patient."

Observation on 03/05/19 between 3:55 PM to 4:25 PM during a tour of facility location C outpatient services revealed the following:

1. Observation of the Cardiovascular Imaging outpatient department gamma bed revealed a one inch slit in the clear vinyl cover. The one inch slit in the vinyl cover left the bed surface non-cleanable.

Interview with the Nuclear Medicine Technician (NMT) A at 3:55 PM on 03/05/19 confirmed the Gamma bed had been in service the past four and a half years. NMT A stated she was not aware of the slit in the vinyl cover and shared the cover needed to be replaced.

2. Observation on 03/05/19 between 4:15 PM and 4:25 PM during the tour of the outpatient Cardiac/Pulmonary Rehab and Physical Therapy (PT) Rehabilitation (Rehab) department revealed the following:

Observation of room five treatment table revealed the pillow had a two-inch tear in the seam exposing the inner pylon fiber that left the surface non-cleanable.

Observation during the tour of the PT Rehab gym area revealed the treatment table pillow surface cracked with an inch circular hole exposing the inner pylon fiber that left the surface non-cleanable.

Further observation on 03/05/19 of the PT Rehab treatment area revealed the surface of two vinyl pads with four open areas on the seam, two open areas were three inches in length and the other two areas were six to eight inches in length. The open area exposed the foam interior which left the surface non-cleanable. The vinyl pads were approximately 20 inches by 20 inches square and used as a cushion for patients when applying heat packs.

Interview with the Rehabilitation Manager (RM) B at 4:25 PM verified he was not aware of the tears in the pillows or the separated seams in the treatment pads. RM B confirmed the policy is to remove any cracked or torn equipment from the treatment area.