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Based on document review, policy and procedure review and staff interview, the hospital failed to have in place an effective method for the administration of drugs. In four (4) of four (4) medication charts reviewed, the agency failed to give medications in a timely manner.

Findings include:

1. Review of four (4) of 10 medication records revealed four (4) of these (records) had medications given late. The hospital has a computer program where the reason for late disposition of medications can be noted. In these four (4) records, the reason was not noted.

2. In an interview with the Chief Nursing Officer on April 25, 2012, at 2:00 p.m., she stated that she has not updated the policies regarding the one (1) hour disposition period for time-critical scheduled medications because they can not figure out exactly how to do it. She stated that by the time they scan the arm band and each medication and open it and give it, even with just five (5) to six (6) patients it takes the nurse longer than one (1) hour. She stated she is exploring several different solutions.

3. The findings were revealed during exit on April 25, 2012 at 4:30 p.m. No further information was provided by the facility.

Based on observation, and testing, the hospital failed to be constructed, arranged, and maintained to ensure the safety of patients.


Findings include:


Refer to A709 for the hospital's failure to comply with the Life Safety Code, and A710 for the hospital's failure to comply with the applicable provisions of the Life Safety Code of the National Fire Protection Association.

Based on observation and testing, the hospital failed to be constructed, arranged, and maintain to ensure the safety of the patients.


Findings include:

The standard of Life Safety Code is considered not met due to the hospital's failure to comply with the applicable provisions of the Life Safety Code of the National Fire Protection Association. Refer to A710

Based on observation and testing, the hospital failed to be constructed, arranged, and maintained to ensure the safety of the patients.


Findings include:

1. Refer to K-011 - The hospital failed to provide the two (2) hour fire separation between nonconforming building.

2. Refer to K-020 - The hospital failed to provide shaft partitions that have a fire resistance rating of at least one (1) hour.


3. Refer to K-025 - The hospital failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.3, 19.1.6.4.


4. Refer to K-029 - The hospital failed to provide the smoke resisting partitions and doors in accordance with 8.4.1 and/or 19.3.5.4.


5. Refer to K-030 - The hospital failed to provide the Gift Shop to be protected as a hazardous area when used for storage or display of combustibles in quantities considered hazardous.

6. Refer to K-052 - The hospital failed to provide a properly tested and maintained fire alarm system. This condition affected 100% of the residents and staff as all smoke compartments were affected. NFPA 72 Section 1-5.6.