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Based on observation with tour of the facility, interview, and record review, the physical plant and overall hospital environment were not maintained in such a manner that the safety and well-being of patients and staff were assured. The facility had uncontrolled access to facility electrical control panel room, facility chiller room, facility roof and emergency department clinical, supply and medication areas. The facility had unsecured access to the hospital facility through the loading dock.

Findings included:

Observation on 2/5/2025 at 08:10 am. Surveyor accessed exterior door labeled "Stair G" which was closed and unlocked. This stairwell led to the facilities electrical control panel room which had an unlocked door and was unattended. In addition, it led to a large facilities workroom with chiller controls for the facility. Lastly, it led to a rooftop access, above the emergency room, where surveyor walked through a roof access door, propped open with a piece of wood, onto the facility's roof.

Observation on 2/5/2025 at 08:20 am. Survey team entered the loading dock doors in the rear of the facility, which had signage stating they were locked and to press button for assistance. However, the left door opened when attempted to enter. Survey team walked down hallway, which had numerous linen carts, lined up on the right side of the hallway. The last linen cart was observed to have numerous sets of teal hospital issued scrubs which were unsecured. Survey team continued straight and turned right into West tower first floor. Survey team walked through the hallways and entered the emergency department clinical areas, medication preparation area with pyxis and unsecured patient care supplies which included numerous IV catheter needles and butterfly needles situated on adjacent counter.

Observation on 2/5/2025 at 08:30 am. Survey team encountered a male (he identified himself as Vendor Staff ID #92). He was dressed in navy blue scrubs with a disposable red bouffant cap in place. He did not have a visible ID badge. He walked directly into the loading dock doors to access the facility. Survey team confirmed his status as a vendor and he stated he was "going to the operating room." He stated this was the "closest entrance so he wouldn't get lost."

Observation on 2/5/2025 at 10:20 am. Surveyor re-toured the prior accessed areas with ED Director Staff ID #76 and Patient Safety Specialist Staff ID #55. Surveyor accessed exterior door labeled "Stair G" which was now propped open with a yellow plastic "caution" floor sign. This stairwell led to the facilities electrical control panel room which had an unlocked door and was unattended. The central door was propped open with a fire extinguisher. In addition, it led to a large facilities workroom with chiller controls for the facility. Lastly, it led up another set of steps to a rooftop access, above the emergency room, where surveyor walked through a roof access door, propped open with a piece of wood, onto the facility's roof. The roof was noted to have numerous air conditioning units.

Record review of NFPA 99 Health Care Facility Code, 2012 edition stated "Chapter 13 Security Management." It stated "13.4 Security-Sensitive Areas. 13.4.2 Emergency department security shall include appropriate protection, including the following: 1. Control and limitation of access by the general public ... 3. Access control of the treatment area." It further stated "13.4.4 Medication storage and work areas shall be secured against admittance of unauthorized personnel through the use of the following: 1) access control 2) unique identification for the area 3) secure storage ..." NFPA Security Management code stated "13.5.3 Health care facility security controls and procedure shall comply with life safety requirements for egress." It further stated "13.8.2 The security management plan shuld include processes and procedures fro controlling access to the health care facility. 13.8.2.1. Exterior entrances shall be provided with locking devices. 13.8.2.2. Locking devices shall comply with applicable federal, state and local requirements. 13.8.2.3 Locking devices shall be properly installed and be in good working order."

Record review of facility's "Security Officer Duty Schedule" provided by Director of Security Staff ID # 63. It stated "Daily: ... Ensures security of all designated areas and access points." The description of assigned duties further stated "Controls access of areas and of materials by administering and enforcing building visitors and materials pass programs."

Record review of facility procedure "Hospital Visitation: General, After Hours and Access Control", last revised 11/14/2023, stated "Procedure Purpose: To provide after-hours visiting and access control measures that expedite patient care and provide for the security and safety of visitors, patients and staff of (facility)." It further stated "Employees, contract labor, and medical staff members must display an approved identification badge during these times to be allowed access. Visitation access for visitors may be made through the main entrance until 9:00 p.m."

Interview with Contractor Staff ID #78 on 2/5/2025. He confirmed he was a contracted vendor who had been working in the facility for "months." He stated that the electrical control panel room and chiller control rooms had remained "unlocked for 3 months."

Interview with ED Director Staff ID # 76 on 2/5/2025 at 10:40 am while on tour. She confirmed surveyors finding of access to the building from the unlocked loading dock doors and walking through the hallways allowed access to the emergency department clinical areas, medication preparation area with pyxis and unsecured patient care supplies including numerous IV catheter needles and butterfly needles which were situated on adjacent counter. She confirmed that the current construction in the emergency department had caused controlled access doors to be removed.

Interview with Director of Security Staff ID #63 on 2/5/2025 at 12:45 pm. He confirmed that all exterior entrances to the facility should be secured or locked except for the main West tower lobby entrance, ED entrance which was manned by security staff and a badge only access entrance for employees in the East Tower. He confirmed that exterior doors with controlled access, locks or badge readers, should not be propped open and accessible to enter the facility.

Interview with Chief Operating Officer Staff ID #74 on 2/5/2025 at 2:10 pm. She confirmed that the West Tower has emergency department and operating room expansion/construction efforts under way. She confirmed that the facility should not have doors propped open and unlocked despite the construction in progress.