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Based on observation, document review, and staff interview, it was determined that the facility failed to ensure the means of egress are maintained free and available for instant use in the event of a fire or other emergency.

Findings include:

1. On 1/29/20 at 11:30 AM, in the presence of Staff #33, a revolving door with two (2) solid wedge sections located on opposite sides of the revolving door were identified as an exit door by an illuminated EXIT sign in the Emergency Department Waiting Room. This revolving door was the main exit from the waiting room and leads directly to the outside.

a. These solid wedges block 100 percent of the exit opening when the door stops rotating.

(i) During an interview on 1/29/20 at 11:35 AM, Staff #33 stated, "if the revolving door stopped in a position that placed the solid wedge sections across the exit opening, a person would be required to manually rotate the revolving door to the opening to exit."

(ii) During a review of the hospital Construction Plans Page A0-1.2, dated 6/11/10, the revolving door was identified as a means of egress.

(iii) Staff #33 confirmed these findings.

This finding resulted in an Immediate Jeopardy (IJ). The Administrator was informed of the IJ and was provided with the IJ Template on 1/29/20 at 4:05 PM.

On 1/30/20, the facility submitted an acceptable Removal Plan for the Immediate Jeopardy findings.

On 2/5/20, an on-site revisit was conducted. It was determined that the facility had disabled the revolving door in the Waiting Area, and installed a temporary door equipped with panic hardware for immediate egress. In addition, the facility had posted Security Officers in the ED Waiting Area 24 hours a day, 7 days a week. As a result of this revisit the Immediate Jeopardy for K211 was removed as of 2/5/20.

Based on observation and staff interview, it was determined that the facility failed to ensure that valves controlling the water supply to the required automatic sprinkler system are supervised and monitored for integrity.

Findings include:

1. On 1/29/20 at 11:45 AM, in the presence of Staff #33, the water supply for the required automatic sprinkler system was lacking supervisory signaling devices which would alert staff if the water supply was shut off.

a. During an interview on 1/29/20 at 2:30 PM, Staff #33 confirmed that the valves controlling the water supply for the sprinkler system were not electronically supervised to automatically transmit an audible and visual signal to a constantly attended location or remote receiving location.

This finding resulted in an Immediate Jeopardy (IJ). The Administrator was informed of the IJ and was provided with the IJ Template on 1/29/20 at 4:05 PM.

On 1/30/20, the facility submitted an acceptable Removal Plan for the Immediate Jeopardy findings.

On 2/5/20, an on-site revisit survey was conducted. It was determined that the facility had conducted hourly fire watch in the Pump Room. The hourly fire watch will be conducted until a permanent electronic monitoring system is in place. As a result of this revisit survey, the IJ for Tag K352 was removed.