HospitalInspections.org

This was an un-announced verification visit on 06/20/2013 as part of a standard Recertification Survey for Life Safety Code compliance, conducted by the Wisconsin Division of Quality Assurance to the original survey on 04/22/2013 through 4/25/2013. The Milwaukee County Behavioral Health Division (facility) was found to be NOT in compliance with the following applicable regulations for hospital participation in Medicare-Medicaid:

42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET

The facility was surveyed under the 2000 Life Safety Code, Chapter 19 for an Existing Health Care Occupancy (Hospital) and Chapter 39 for an Existing Business Occupancy (Food Services Bldg.).

FINDINGS INCLUDED: Twelve (12) federal deficiencies of the Life Safety Code were found to be outstanding based on the recent Verification Visit:

K-18 (corridor doors),
K-22 (exit signs),
K-27 (smoke barrier doors),
K-29 (hazardous spaces),
K-34 (exit stairway),
K-38 (egress access),
K-45 (general means of illumination - dbl. bulbs),
K-62 (sprinkler system maintenance),
K-69 (fire protection of commercial cooking operations),
K-76 (medical gas storage),
K-103 (limited combustible partitions),
K-147 (electrical wiring).

(please see the individual K-tags for further detail)
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Based on observation and review of maintenance records, the facility including Building #03 (Food Service Building) & Building #04 (Hospital) did not maintain the condition of the physical plant and overall hospital environment in a manner to ensure the safety and well-being of patients. The facilities did not have ceilings & doors free of damage and handrails free of damage. This deficiency had the potential to affect patients, staff and visitors within 2 of the 22 smoke compartments.

FINDINGS INCLUDE:
1. On 02/22/2013 at 2:49 pm, observation revealed on the 1st Floor floor of Building #4, in the Clean Food Storage area next to Food Production, that a portion of the ceiling was damaged and in need of repair. The ceiling was observed to have 2 full ceiling tiles and one light fixture lens stained due to moisture coming through the floor above. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This observed situation was not compliant with 42 CFR 482.41(a). These deficiencies have been previously approved for correction on August 1, 2013.

4. On 02/23/2013 at 4:46 pm, observation revealed on the Wing area 5/ Level 3-B floor of Building #3, in the Corridor near Stairwell 5-5, that a portion of the 'handrail' was damaged and in need of repair. The handrail was observed without the turned-in cap to wall required by Code. And based on the unique patient population, the handrails must be provided with a closure plate near its bottom, to prevent any item passing through the handrail that could be used by the patient (in a negative way) to hurt themselves. The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). This damage renders this 'handrail' dangerous to the patient population. This observed situation was not compliant with 42 CFR 482.41(a). These handrails have been previously approved for correction on August 1, 2013.


12. On 02/22/2013 at 2:10 pm, observation revealed on the 1st Floor floor in the Food Services Building at the Production Kitchen to the Loading Dock, that the corridor door would not positively self-latch. The fire-rated door was equipped with a closer, but it would not hold the door in the latched position. The metal doors were warped due to being hit by many carts to prevent them from closing and latching. When the doors were propped-open, it would cause an air imbalance, based on the 'tissue test' at the door meeting edge. The air from the dirty Loading Dock area could compromise the clean air on the sanitary Food Production side per 42 CFR 482.41 Environment Condition. It could not be confirmed the loading dock was of negative pressure to the production kitchen side (clean to dirty). The condition was confirmed at the time of discovery by a concurrent observation and interview with staff F (Utilities Engineer) and staff Y (Maintenance Supervisor). These doors have been previously approved for correction on August 16, 2013.
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A standard Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 04/22/2013 through 4/25/2013. The Milwaukee County Behavioral Health Division (facility) was found to be NOT in compliance with the following applicable regulations for hospital participation in Medicare-Medicaid:

42 CFR 482.41(b) Standard: Safety from Fire was NOT MET.

The facility was surveyed under the 2000 Life Safety Code, Chapter 19 for an Existing Health Care Occupancy (Hospital) and Chapter 39 for an Existing Business Occupancy (Food Services Bldg.).

FINDINGS INCLUDED: Twelve (12) federal deficiencies of the Life Safety Code were outstanding as follows:

K-18 (corridor doors),
K-22 (exit signs),
K-27 (smoke barrier doors),
K-29 (hazardous spaces),
K-34 (exit stairway),
K-38 (egress access),
K-45 (general means of illumination - dbl. bulbs),
K-62 (sprinkler system maintenance),
K-69 (fire protection of commercial cooking operations),
K-76 (medical gas storage),
K-103 (limited combustible partitions),
K-147 (electrical wiring).

(please see the individual K-tags for further detail)
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