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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:

Main Hospital Building
K29: The facility did not enclose hazardous rooms that had rated doors.
K38: The facility did not provide egress paths with sufficient headroom.
K130: The facility failed to provide unoccupied rooms from opening onto stairs.

Stoughton Clinic: K130: The facility failed to provide a safe path to a public way.

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, and staff interviews, the facility to install proper ventilation systems. This deficiency occurred in 1 of the 15 smoke compartments, and had the potential to affect 2 of the 35 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On 3/31/2011 at 12:10 pm surveyor #22219, #13960, and #22994 observed in the #1 smoke compartment on the 3rd floor in the ICU rooms, 372 & 371, that the facility failed to install a proper ventilation system. An unenclosed toilet was located in one corner of the 16'x16'x9' high patient care room. The ceiling above the toilet had an exhaust grill that staff A (Director of Plant Operations) said had an air flow of approximately 75 cubic feet per minute (cfm). Staff A (Director of Plant Operations) said the entire room had about 6 air changes per hour of supply and return air. The room was observed to have a slight negative pressure, as evidenced by the inward movement of a slip of toilet paper when held by the slightly open door. The toilet space had cubical curtains that separated it from the rest of the rooms. Since there were not solid walls and a door to enclose the toilet space, the ventilation standard of 10 air changes of exhaust air for the toilet space, which was open to the patient room, applied to the entire room. The provided ventilation for the overall space calculated to be less than 2 exhaust air changes per hour. This observed situation was not compliant with CFR 482.41(c) and the Wisconsin Mechanical Code. The situation was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Plant Operation), staff B (Environmental Services Manager), staff C (President), and staff D (Lead Maintenence Worker).

This observation was also made during the original recertification survey on January 5, 2011. The facility's Plan of Correction was to request a hardship waiver. Sufficient information was not received at the time of the verification visit to support a waiver request.

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:

Main Hospital Building
K29: The facility did not enclose hazardous rooms that had rated doors.
K38: The facility did not provide egress paths with sufficient headroom.
K130: The facility failed to provide unoccupied rooms from opening onto stairs.

Stoughton Clinic: K130: The facility failed to provide a safe path to a public way.

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.