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Tag No.: A0700
Based on observation and interview, the facility failed to ensure exit signs were posted in accordance with Edition 2012 of NFPA 101, Life Safety Code, failed to ensure door separating hazardous areas were provided with self-closing devices, failed to ensure smoke detectors were installed in areas open to the exit corridor, failed to ensure sprinklers were installed throughout the main hospital building, failed to ensure corridor door systems were provided with positive latching hardware and failed to ensure portable space heaters were prohibited (A-0709 and A-0710. The cumulative effect of these systemic practices resulted in the facility's inability to ensure a safe environment for all 45 patients.
Tag No.: A0709
Based on observation and interview, the facility failed to meet the requirements for life safety; specifically, the applicable provisions of 42 CFR §482.41 and Edition 2012 of the National Fire Protection Association Life Safety Code, Chapter 19, Existing Health Care Occupancies. This had the potential to affect all 45 patients.
Findings include:
Please see life safety code report for more details.
1. Refer to K-0293 exit signage;
2. Refer to K-0321 hazardous areas - enclosure;
3. Refer to K-0347 smoke detection;
4. Refer to K-0351 sprinkler system - installation; and
5. Refer to K-0781 portable space heaters.
Tag No.: A0710
Based on observation and interview, the facility failed to meet the requirements for life safety; specifically, the applicable provisions of 42 CFR §482.41 and Edition 2012 of the National Fire Protection Association Life Safety Code, Chapter 19, Existing Health Care Occupancies. This had the potential to affect all 45 patients.
Findings include:
Please see life safety code report for more details.
1. Refer to K-0363 corridor door.
Tag No.: A0748
Based on personnel file review, interview and policy review, the facility failed to implement policies governing control of infections and communicable diseases for eleven (Staff L, N, O, P, S, T, U, V, W, X and Z) of 14 medical staff personnel files reviewed. This had the potential to affect the facility's 45 active patients.
Findings include:
The facility's Colleague, Volunteer, and Independently Contracted Individuals Health Screening Infection Prevention policy (Effective Date: 10/85 Current Review/Revision Date: 08/17) stated:
6. Annual Tuberculosis (TB) Screening Survey will be completed with low risk results of the risk assessment. A registered nurse (RN) will review and determine if a Tuberculin Skin Test (TST) is warranted with any colleague having signs or symptoms or questioning possible exposure to TB.
Review of 14 medical staff personnel files on 11/21/19 at approximately 3:10 PM revealed Staff L, N, O, P, S, T, U, V, W, X and Z did not complete an annual TB screening form during the previous 12-month period.
The findings were shared with Staff M on 11/21/19 at approximately 3:10 PM and confirmed.