HospitalInspections.org

This was a Verification Visit tour of the facility with Staff B (Interim Dir. of Quality), Staff D (Risk Manager) and Staff H (Director of Plnt. Srvs.) and follow-up exit interview with Staff A (CEO), B (Interim Dir. of Quality), C (Asst. Adm.-Patient Care Srvs.), D (Risk Manager) and H (Director of Plnt. Srvs.) 01/21/2010; Surveyor #18107 observed the hospital was still in-progress correcting the following citations below under Physical Environment requirements of the '2000 Edition of the Life Safety Code' for the "Existing Healthcare occupancies chapter" of the National Fire Protection Association (NFPA) for the safety of patients, staff and visitors. Refer to the original deficiencies (dated 02/17/2009) identified in the Life Safety Survey Report for complete details.

FINDINGS INCLUDE:

It was observed that the hospital still failed to comply with the following requirements:
K-17 (Smoke-Tight Corridors),
K-20 (Shafts & Openings between Floors),
K-21 (Doors in Exit Passageways & Smoke Barriers),
K-25 (Smoke Barriers),
K-29 (Hazardous Areas),
K-32 (Required Two Exits per Fire Area),
K-36 (Travel Distance),
K-38 (Exit Access), and
K-104 (Penetration of Smoke Barriers by Ducts).

The continued cumulative affect of these environmental deficiencies result in the hospital's inability to provide a safe environment for all patients, visitors and staff. Completion of all the above is due 02/2010 per the plan of correction and approved by CMS-Region 5.