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Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the 2000 Edition of the Life Safety Code for "New Healthcare Occupancy" and also "Existing Healthcare Occupancy" chapters of this code.

The findings include:
K11: The facility did not provide a common separation wall with rated wall construction.
K18: The facility did not provide corridor separation doors with smoke-tight seals at meeting edges.
K29: The facility did not enclose hazardous rooms with a rated door and door closer.
K48: The facility did not maintain a written evacuation plan that contained all the elements with staff trained on life safety procedures.
K130: The facility did not provide a code compliant environment with suite travel distance under the required limits

The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable systems to ensure safety to all occupants, patients and staff of this facility.

Based on observation, staff interviews and review of maintenance records, the facility did not construct, install and maintain a proper ventilation and temperature control system in pharmaceutical, food preparation, and other appropriate areas. The facility did not have a ventilation system that was installed and maintained in accordance with state regulations and manufacturer recommendations. This deficiency occurred in 2 of the 8 smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

2) On January 29, 2013 at 9:45 am, and on March 18, 2013 at 10:00 am observation revealed on the lover level floor in the Surgery area, in the dirty Utility room, that the ventilation to the space could not be confirmed to be compliant with accepted standards. The air flow was from dirty to clean when the outside door to this suite was open to the corridor. This observed situation was not compliant with 42 CFR 482.41(c)(4).

3) On January 29, 2013 at 11:00 am, observation and review of records revealed on the lower level floor in the Operating rooms 1 and 2, that the ventilation to the space could not be confirmed to be compliant with accepted standards. The relative humidity in the Operating room 1 was below 30 % in the month of January on the 15, 22, 23, and 25th. It was below 19% on January 8th in OR 2. The require range for relative humidity is 30 to 60 %. This observed situation was not compliant with 42 CFR 482.41(c)(4).
On March 18, 2013 at 11;00 am the relative humidity was 28%.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Physical Plant Director).
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Based on observation, staff interviews, and review of maintenance records, the hospital failed to ensure the physical environment of the building met the minimum requirements of the 2000 Edition of the Life Safety Code for "New Healthcare Occupancy" and also "Existing Healthcare Occupancy" chapters of this code.

The findings include:
K11: The facility did not provide a common separation wall with rated wall construction.
K18: The facility did not provide corridor separation doors with smoke-tight seals at meeting edges.
K29: The facility did not enclose hazardous rooms with a rated door and door closer.
K48: The facility did not maintain a written evacuation plan that contained all the elements with staff trained on life safety procedures.
K130: The facility did not provide a code compliant environment with suite travel distance under the required limits

The cumulative effect of these deficiencies indicates that the facility failed to provide a safe environment and reliable systems to ensure safety to all occupants, patients and staff of this facility.