HospitalInspections.org

Based on observation, interview and review of policies and construction documents, the governing body failed to be responsible for services provided under contact and remain compliant with The Centers for Medicare and Medicaid Services Conditions of Participation, the National Fire Protection Association fire code specifications and the hospital's policies and procedures. The failure to comply with the standards for safety placed all patients, visitors and staff at risk for injury and/or death in the event of a fire.

Findings include:

- The hospital's policy titled "Construction/Remodeling", reviewed on 9/20/13 at 9:30am, revealed "To provide the best possible protection for patients, visitors and employees from potential infection during and past construction". The procedure includes "A. Preventative measures to be used: 1. A wall barrier should be used, floor to ceiling, dry wall with door or airtight plastic barrier will be used to separate the construction site from the hospital area" and "1.c. Barrier should meet the NFPA (National Fire Protection Association) fire code specifications".

- During the tour conducted by the fire marshal on 09/17/13, at approximately 3:30 p.m., it was observed that in construction and remodeling areas in the 1st floor of the hospital egress pathways have dust confinement walls constructed of wood and plastic. Egress pathways were not protected by one hour fire-rated construction. At least one patient (in a wheelchair), several visitors and hospital staff were observed traversing through the construction area. On 9/18/13, at approximately 2:00 p.m., in a meeting with hospital management personnel, maintenance staff, construction supervisors and the hospital's architect, discussion was held regarding prohibition of egress through construction areas and the necessity for OSFM (Office of State Fire Marshal) approved plans for temporary exiting during construction. On 09/19/13, at 7:49 a.m., the fire marshal placed a telephone call to the Chief of Fire Prevention for the Office of the State Fire Marshal, advising of the scope of construction and status of exiting at this hospital. The information was then relayed to the CMS (Centers for Medicare and Medicaid Services) Regional Office Representative by the Chief of Fire Prevention. During a telephone conference between the CMS Regional Office Representative, the Chief of Fire Prevention and the fire marshal, commencing at 10:16 a.m. on 09/19/13, it was determined by the CMS Representative that the hospital should be placed in an Immediate Jeopardy status. Notification of the Immediate Jeopardy status and the necessity for Fire Watch was provided to the hospital staff by the Chief of Fire Prevention.

On-site contractors were in the process of constructing 1-hr rated walls/corridors to assure
safe and protected passage through areas affected by the construction process. On 09/20/13, after a tour of the hospital and verification that affected areas were separated
from use areas by 1-hr construction and that appropriate egress pathways were in place, the
Immediate Jeopardy status was abated at 8:12a.m. The Fire Watch process was terminated at 8:44 a.m. by the Fire Protection Specialist with the Office of the State Fire Marshal after approval of temporary egress plans. NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

- Policies provided by Hutton Construction Company titled Environmental- Infection Control Risk Assessment", reviewed on 9/20/13 at 10:35am, revealed a "Risk Assessment shall identify: the type of construction project activity, the patient risk groups, the patient risk groups surrounding the work area, above and below" and "the required infection control procedures to be used on the project".

The hospital provided evidence of an "Infection Control Risk Assessment" dated 4/10/13 for "Admin Demo", which expired on 4/10/13. The hospital lacked evidence of an "Infection Control Risk Assessment" for the additional construction phases completed, under construction or planned.

- Observation of the first floor of the hallway adjoining the medical clinic and the hospital's main entrance on 9/19/13 revealed construction activities including removal of walls and carpeting, the presence of tools and supplies and a hole in the exterior wall.

- Infection Prevention nurse B, interviewed on 9/20/13 at 10:20am acknowledged the lack of a construction "Risk Assessment" for the areas of the hospital currently under construction and for all planned construction.

The Governing Body failed to maintain responsibility for the hospital services provided by the contracted construction company and failed to comply with the Centers for Medicare and Medicaid Services Conditions of Participation, National Fire Protection Association requirements and the hospital and contractor policies and procedures.

Based on observation, document review and staff interview, the hospital failed to construct, arrange and maintain the hospital to ensure the safety of all patients, visitors and staff. The hospital failed to assure hazardous areas are protected (A701), failed to meet the fire safety standards (A710) and failed to assure the hospital is maintained at acceptable standards (A724).


The cumulative effect of these systemic problems resulted in the Hospital's inability to ensure patients, visitors and staff safety from fire.

Based upon observation, document review and staff interview, the hospital failed to assure hazardous areas are protected in accordance with 2000 NFPA (National Fire Protection Association) 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1. The deficient practice increased the risk of fire or smoke spreading to other areas of the building, affecting approximately 5 patients, all staff and visitors in 3 of 19 smoke zones. The hospital has a capacity of 69 with a census of 21 on 9/17/13. The failure to comply with the standards for fire safety placed all patients, visitors and staff at risk in the event of a fire.

Findings include:

- The tour conducted by the fire marshal on 9/17/13, at approximately 3:30 p.m., revealed construction and remodeling areas in the 1st floor of the hospital egress pathways have dust confinement walls constructed of wood and plastic. Egress pathways were not protected by one hour fire-rated construction. At least one patient (in a wheelchair), several visitors and hospital staff were observed traversing through the construction area. On 9/18/13, at approximately 2:00 p.m., in a meeting with hospital management personnel, maintenance staff, construction supervisors and the hospital's architect, discussion was held regarding prohibition of egress through construction areas and the necessity for OSFM (Office of the State Fire Marshal) approved plans for temporary exiting during construction. On 9/19/13, at 7:49 a.m., the fire marshal placed a telephone call to the Chief of Fire Prevention for the Office of the State Fire Marshal, advising of the scope of construction and status of exiting at this hospital. The information was then relayed to the CMS (Centers for Medicare and Medicaid Services) Regional Office Representative by the Chief of Fire Prevention. During a telephone conference between the CMS Regional Office Representative, the Chief of Fire Prevention and the fire marshal, commencing at 10:16 a.m. on 9/19/13, it was determined by the CMS Representative that the hospital should be placed in an Immediate Jeopardy status. Notification of the Immediate Jeopardy status and the necessity for Fire Watch was provided to the hospital staff by the Chief of Fire Prevention.

On-site contractors were in the process of constructing 1-hr rated walls/corridors to assure safe and protected passage through areas affected by the construction process. On 9/20/13, after a tour of the hospital and verification that affected areas were separated
from use areas by 1-hr construction and that appropriate egress pathways were in place, the Immediate Jeopardy status was abated at 8:12a.m. The Fire Watch process was terminated at 8:44 a.m. by the Fire Protection Specialist with the Office of the State Fire Marshal after approval of temporary egress plans. NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

The hospital's failure to meet the Life Safety Code of the National Fire Protection Association placed patients, visitors and staff at risk.

See the results of the life safety code survey completed on 9/26/13.

Based upon observation and staff interview, the hospital fails to assure that hazardous areas are protected in accordance with 2000 NFPA (National Fire Protection Association) 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1 The deficient practice increases the risk of fire or smoke spreading to other areas of the building, affecting approximately 5 patients, all staff and visitors in 3 of 19 smoke zones. The hospital has a capacity of 69 with a census of 21 on 9/17/13. The hospital's inability to assure the safety of patients, visitors and staff from fire resulted in immediate jeopardy. The immediate jeopardy was abated on 9/20/13 at 8:12am. The failure to comply with the standards for safety placed all patients, visitors and staff at risk for injury and/or death in the event of a fire.

Findings include:

- During the tour conducted by the fire marshal on 09/17/13, at approximately 3:30 p.m., it was observed that in construction and remodeling areas in the 1st floor of the hospital egress pathways have dust confinement walls constructed of wood and plastic. Egress pathways were not protected by one hour fire-rated construction. At least one patient (in a wheelchair), several visitors and hospital staff were observed traversing through the construction area. On 9/18/13, at approximately 2:00 p.m., in a meeting with hospital management personnel, maintenance staff, construction supervisors and the hospital's architect, discussion was held regarding prohibition of egress through construction areas and the necessity for OSFM(Office of the State Fire Marshal) approved plans for temporary exiting during construction. On 09/19/13, at 7:49 a.m., the fire marshal placed a telephone call to the Chief of Fire Prevention for the Office of the State Fire Marshal, advising of the scope of construction and status of exiting at this hospital. The information was then relayed to the CMS (Centers for Medicare and Medicaid Services) Regional Office Representative by the Chief of Fire Prevention. During a telephone conference between the CMS Regional Office Representative, the Chief of Fire Prevention and the fire marshal, commencing at 10:16 a.m. on 09/19/13, it was determined by the CMS Representative that the hospital should be placed in an Immediate Jeopardy status. Notification of the Immediate Jeopardy status and the necessity for Fire Watch was provided to the hospital staff by the Chief of Fire Prevention.

On-site contractors were in the process of constructing 1-hr rated walls/corridors to assure
safe and protected passage through areas affected by the construction process. On 09/20/13, after a tour of the hospital and verification that affected areas were separated
from use areas by 1-hr construction and that appropriate egress pathways were in place, the
Immediate Jeopardy status was abated at 8:12a.m. The Fire Watch process was terminated at 8:44 a.m. by the Fire Protection Specialist with the Office of the State Fire Marshal after approval of temporary egress plans. NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

The hospital's failure to meet the Life Safety Code of the NFPA placed patients, visitors and staff at risk.

See the results of the life safety code survey completed on 9/26/13.

Based on observation, interview and review of policies and construction documents, the hospital failed to maintain the hospital at an acceptable level of safety and remain compliant with The Centers for Medicare and Medicaid Services Conditions of Participation, the National Fire Protection Association fire code specifications and the hospital's policies and procedures. The failure to comply with the standards for safety placed all patients, visitors and staff at risk for injury and/or death in the event of a fire.

Findings include:

- The hospital's policy titled "Construction/Remodeling", reviewed on 9/20/13 at 9:30am, revealed "To provide the best possible protection for patients, visitors and employees...includes "A. Preventative measures to be used: 1. A wall barrier should be used, floor to ceiling, dry wall with door or airtight plastic barrier will be used to separate the construction site from the hospital area" and "1.c. Barrier should meet the NFPA (National Fire Protection Association) fire code specifications".

- During the tour conducted by the fire marshal on 09/17/13, at approximately 3:30 p.m., it was observed that in construction and remodeling areas in the 1st floor of the hospital egress pathways have dust confinement walls constructed of wood and plastic. Egress pathways were not protected by one hour fire-rated construction. At least one patient (in a wheelchair), several visitors and hospital staff were observed traversing through the construction area. On 9/18/13, at approximately 2:00 p.m., in a meeting with hospital management personnel, maintenance staff, construction supervisors and the hospital's architect, discussion was held regarding prohibition of egress through construction areas and the necessity for OSFM(Office of the State Fire Marshal) approved plans for temporary exiting during construction. On 09/19/13, at 7:49 a.m., the fire marshal placed a telephone call to the Chief of Fire Prevention for the Office of the State Fire Marshal, advising of the scope of construction and status of exiting at this hospital. The information was then relayed to the CMS (Centers for Medicare and Medicaid Services) Regional Office Representative by the Chief of Fire Prevention. During a telephone conference between the CMS Regional Office Representative, the Chief of Fire Prevention and the fire marshal, commencing at 10:16 a.m. on 09/19/13, it was determined by the CMS Representative that the hospital should be placed in an Immediate Jeopardy status. Notification of the Immediate Jeopardy status and the necessity for Fire Watch was provided to the hospital staff by the Chief of Fire Prevention.

On-site contractors were in the process of constructing 1-hr rated walls/corridors to assure
safe and protected passage through areas affected by the construction process. On 09/20/13, after a tour of the hospital and verification that affected areas were separated
from use areas by 1-hr construction and that appropriate egress pathways were in place, the
Immediate Jeopardy status was abated at 8:12a.m. The Fire Watch process was terminated at 8:44 a.m. by the Fire Protection Specialist with the Office of the State Fire Marshal after approval of temporary egress plans. NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1.

The hospital's failure to meet the Life Safety Code of the NFPA placed patients, visitors and staff at risk.

See the results of the life safety code survey completed on 9/26/13.

- Observation of the first floor of the hallway adjoining the medical clinic and the hospital's main entrance on 9/19/13 revealed construction activities including removal of walls and carpeting, the presence of tools and supplies and a hole in the exterior wall.

- Infection Prevention nurse B, interviewed on 9/20/13 at 10:20am acknowledged the lack of a construction "Risk Assessment" for the areas of the hospital currently under construction and for all planned construction.

The hospital failed to maintain the facilities in compliance with the Centers for Medicare and Medicaid Services Conditions of Participation, National Fire Protection Association requirements and the hospital and contractor policies and procedures.

Based on observation, interview and review of policies and construction documents, the infection control officer failed to be responsible for services provided under contact and remain compliant with The Centers for Medicare and Medicaid Services Conditions of Participation and the hospital's policies and procedures for infection control. The failure to comply with the standards for infection control placed all patients, visitors and staff at risk for infection.

Findings include:

- The hospital's policy titled "Construction/Remodeling", reviewed on 9/20/13 at 9:30am, revealed "To provide the best possible protection for patients, visitors and employees from potential infection during and past construction".

- Policies provided by Hutton construction company (HCA) titled Environmental- Infection Control Risk Assessment", reviewed on 9/20/13 at 10:35am, directs a "Risk Assessment shall identify: the type of construction project activity, the patient risk groups, the patient risk groups surrounding the work area, above and below" and "the required infection control procedures to be used on the project".

The hospital provided evidence of an "Infection Control Risk Assessment" dated 4/10/13 for "Admin Demo", which expired on 4/10/13. The hospital lacked evidence of an "Infection Control Risk Assessment" for the additional construction phases completed, under construction or planned.

- Observation of the first floor of the hallway adjoining the medical clinic and the hospital's main entrance on 9/19/13 revealed construction activities including removal of walls and carpeting, the presence of tools and supplies and a hole in the exterior wall.

- Infection Prevention nurse B, interviewed on 9/20/13 at 10:20am acknowledged the lack of a construction "Risk Assessment" for the areas of the hospital currently under construction and for all planned construction.

The infection control officer failed to maintain accountability for the hospital services provided by the contracted construction company for the prevention of infections.