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THEDACARE REGIONAL MEDICAL CENTER - APPLETON INC
No Description Available
Tag No.: K0011
Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to lack of fire rated occupancy separation wall between the hospital and the medical office building (MOB South) of business occupancy. The observed situation was not compliant with NFPA 101 sections 19.1.1.4.1, 19.1.2.1. This deficient practice affected 1 of 41 smoke compartments in the entire facility.
Findings include:
During a tour of the facility with Staff M1 (vice president, facilities operation), Staff M2 (director of facilities), Staff M3 (facilities supervisor), and Staff M4 (facilities supervisor, Theda Clark MC), Staff M5 (corporate safety officer), Staff M7 (safety specialist), and Staff M8(security supervisor) on 3/5/13, surveyor observed between 9 AM and 12 PM that the Nuclear Medicine located on the 2nd floor of MOB South was not separated from business occupancy with a 2-hr fire rated vertical fire barrier in accordance with NFPA 101 19.1.2.1.
The type of construction, Type II(111), of the 3-story MOB South was compliant with the construction requirement, NFPA 101 19.1.6.2, for health care occupancy due to the building being fully sprinkler protected.
When interviewed on 3/5/13 at 10:50 AM, Staff M12 (nuclear med technician), and M13 (supervisor) stated that mostly outpatients are treated in the two procedure rooms, but some inpatients are also brought in for treatment from the hospital building, and the number of inpatients varies with time and day.
The above deficiency was confirmed the vice president of facilities, facilities supervisor, corporate safety officer, safety specialist, and Staff E (director of pharmacy) at the exit conference on 3/7/13 at 2:30 pm.
As a result of a verification visit on 7/09/13, surveyor determined that the facility was making a satisfactory progress toward correcting the 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 was near completion.
The CMS approved completion date is 5/1/2014.