HospitalInspections.org

Based on observation, staff interview and review of maintenance records between 3/04 -3/12/2013, the facility failed to construct, install, and maintain the building system to ensure safety to all patients, staff and visitors.
Findings include:
Building #01: 4-Story Hospital Building
(i) lack of fire rated occupancy separation wall between the Nuclear Medicine Procedure rooms used by inpatients and outpatients, and the rest of the business occupancy areas on the 2nd Floor of the medical office building (MOB South);
(ii) lack of positive latching in one double leaf corridor doors, and failure to latch in another set of corridor double doors;
(iii) lack of self-closing devices on doors protecting hazardous spaces in two locations;
(iv) obstruction in one means of egress corridor;
(v) Fire Alarm system not installed to minimum standards of NFPA 72, trouble signals not transmitted to and annunciated at the central monitoring station, and lack of evidence of automatic transmission equipment to transmit trouble signals from phone line failure in accordance with NFPA 72 Chapters 1, 5 and 7;

(vi) lack of proper maintenance of batteries for main fire alarm panel;
(vii) lack of maintenance of sprinkler system - dirty sprinkler heads & missing escutcheon plate;
(viii) lack of evidence of the vacuum system station inlet performance test;
(ix) lack of a visual and audible derangement signal at a continuously monitored location for emergency generators of the essential electrical system
(x) Lack of adequate ventilation in one space; and lack of positive and negative pressures in clean and dirty spaces respectively.
See K-11, K-18, K-29, K-39, K-51, K-52, K-62, K-77, K-106, and A-726 for detail.

Building #02: Medical Office Building East
(i) clearance at the meeting edge of double corridor doors too wide;

See K-18 for detail.

Building #03: MRI and Oncology Building
(i) one patient treatment area not separated from corridors;
See K-17 for detail.

Building #05: Medical Office Building South (business occupancy)
(i) one stairwell exit door not latching;

See K-130 for detail.

Building #08: Encircle Health (ambulatory health care and business occupancy)

(i) one hazardous area not protected as a hazardous area.

See K130 for detail.

The cumulative effect of these environment problems resulted in the hospital's inability to ensure a safe environment for the patients.



During a verification visit on 7/09/13, surveyor verified that all deficiencies, except K-11 in Bldg #01 were corrected. Surveyor determined that the facility was making a satisfactory progress toward correcting the K-11 deficiency. When interviewed on 7/9/13, Staff M3 stated that the design drawings and specifications to relocate one of two nuclear med rooms from the medical office building to the hospital were almost completed. The CMS approved completion date is 5/1/2014.

On a verification visit of 7/09/13, all K-tags, except K-11, were verified to have been corrected.

Surveyor determined that the facility was making a satisfactory progress toward correcting the K-11 deficiency. When interviewed on 7/9/13, Staff M3 (facilities supervisor) stated that the design drawings and specifications to relocate one of two nuclear med rooms from the medical office building to the hospital was near completion and would be submitted soon. The CMS approved completion date is 5/1/2014.