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Based on observations, review of available drawings, interview with President and CEO, VP Administration/General Counsel, and VP Operations as referenced in the Life Safety report of survey completed July 28, 2016 through July 29, 2016, the hospital leadership failed to have an effective governing body responsible for the functions of the hospital.

The findings include:

The hospital leadership failed to develop and maintain the facilities in a manner to ensure the health and safety of patients, staff, and visitors.

~cross refer to 482.41 Physical Environment - Condition Tag A0700.

Based on observations, review of available drawings, interview with President and CEO, VP Administration/General Counsel, and VP Operations as referenced in the Life Safety report of survey completed July 28, 2016 through July 29, 2016, the hospital staff failed to develop and maintain the facilities in a manner to ensure the health and safety of patients, staff, and visitors.

The findings include:

1. The hospital failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association assuring the safety and well-being of patients.

~cross-refer to 482.41(b)(1)(2)(3) Physical Environment: Life Safety from Fire - Standard Tag A0710

Based on observations, review of available drawings, interview with President and CEO, VP Administration/General Counsel, and VP Operations as referenced in the Life Safety report of survey completed July 28, 2016 through July 29, 2016, the hospital staff failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association assuring the safety and well-being of patients.

The findings include:

A. Based on observations, review of available drawings, interview with President and CEO, VP Administration/General Counsel, and VP Operations on July 28, 2016 at approximately 3:30 PM onward, the following deficiencies were noted: The facility failed to maintain the required means of egress/exits:

1. Required exits from northwest stairwell on floors 600, 500, 400, and 300 is unusable due to construction zone at former parking area on lobby level; at stairwell exit discharge, NFPA 101, 2000 ed, Section 19.2.5.

2. Required exit from balcony level behind operating room suite, is not available due to construction zone at exit discharge from balcony to former parking area - parking area in question is under renovation as a new patient care area. NFPA 101, 2000 ed, Section 19.2.5.9 Temporary exit stair provided at balcony level fails to meet Section 7.2.2 - 7.2.2.6.6 of NFPA 101, 2000 Edition.

This deficiency affected potentially 188 patient beds, operating room suite alternate exit at lobby level balcony, five corridors, and four of eight smoke compartments. Census affected at time of survey = 196 occupants = staff, patients, and visitors.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Immediate Jeopardy began on January 12, 2016 when renovation contractor constructed impediments to exit discharge at the lobby level of northwest stairwell exit discharge. There was no alternative and acceptable means of egress provided in the affected area. On July 28, 2016 at approximately 3:30 PM onward, the President/CEO, VP Administration/Legal Counsel, and VP Operations were notified that lack of a code compliant alternate exit in referenced areas is not compliant with the Life Safety Code which potentially affects the hospital condition of participation under CMS guidelines. The administration immediately implemented action to discontinue use of affected zones throughout the hospital. The administration were notified of Immediate Jeopardy determination on July 28, 2016 after Life Safety survey of affected areas beginning at 3:30 PM. The facility immediately initiated corrective action by discontinuing use of affected areas, training of staff, and ensuring that existing fire protection systems are not affected by on-going renovations. The facility corrective action verified on-site on July 29, 2016 at approximately 3:30 PM, included the erection of dust barriers, discontinuing use of areas creating excessive travel distances throughout the hospital affected areas.

Immediate Jeopardy was removed on August 3, 2016 when the facility provided and implemented an acceptable credible allegation of compliance.

On July 28, 2016 at approximately 3:30 PM, upon entry to the facility by the LSC Surveyor, based on observations, review of available drawings, interviews with President and CEO, VP Administration/General Counsel, and VP Operations on July 28, 2016 at approximately 3:30 PM onward, the facility failed to maintain the required means of egress/exits. Five required exits being rendered unusable due to new construction at the lobby level exit discharge to the former parking area. The Northwest Egress stairwell, designed to provide an alternate exit for floors 600, 500, 400, and 300 levels was observed discharging through a construction zone and terminating at a scaffolding stair designed for construction workers using protective equipment. The scaffold stair did not conform to minimum design requirements for exit stairs, and was an alternate exit for balcony behind operating room suite. The required exits were taken out of service on January 12, 2016 according to document provided by hospital administration - identified as Incident Command Report dated July 28, 2016. The Administrative Staff was informed of the non-compliance (Immediate Jeopardy) On July 28, 2016 at approximately 3:30 PM, the President/CEO, VP Administration/Legal Counsel, and VP Operations were notified that lack of a code compliant alternate exit in referenced areas is not compliant with the Life Safety Code which potentially affects the hospital condition of participation under CMS guidelines. The administration immediately implemented action to discontinue use of affected zones throughout the hospital. The facility immediately initiated corrective action by discontinuing use of affected areas, training of staff, and ensuring that existing fire protection systems are not affected by on-going renovations. The facility corrective action verified on-site on July 29, 2016 at approximately 3:30 PM, included the erection of dust barriers, discontinuing use of areas creating excessive travel distances throughout the hospital affected areas.

Immediate Jeopardy was abated on August 3, 2016 when the facility provided and implemented an acceptable credible allegation of compliance.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 032

B. Based on observations, review of available drawings, interview with President and CEO, VP Administration/General Counsel, and VP Operations on July 28, 2016 at approximately 3:30 PM onward, the following deficiencies were noted:

Renovation area at exit discharge of Northwest stairwell creates dead end corridors on floors 600 through 300 wing - stairwells on each floor do not lead to an exit discharge terminating in accordance with NFPA 101, 2000 ed, Section 7.7. Scaffold stair, located at lobby level balcony behind operating room area, designed for construction workers is not compliant with Sections, 19.2,5, 7.2.2 through 7.2.2.6.6 of NFPA 101, 2000 Life Safety Code.

This deficiency affected potentially 188 patient beds, operating room suite alternate exit at lobby level balcony, five corridors, and four of eight smoke compartments. Census affected at time of survey = 196 occupants = staff, patients, and visitors on floors 600 through 300.

Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

Immediate Jeopardy began on January 12, 2016 when renovation contractor constructed impediments to exit discharge at the lobby level of northwest stairwell exit discharge. There was no alternative and acceptable means of egress provided in the affected area. On July 28, 2016 at approximately 3:30 PM onward, the President/CEO, VP Administration/Legal Counsel, and VP Operations were notified that lack of a code compliant alternate exit in referenced areas is not compliant with the Life Safety Code which potentially affects the hospital condition of participation under CMS guidelines. The administration immediately implemented action to discontinue use of affected zones throughout the hospital. The administration were notified of Immediate Jeopardy determination on July 28, 2016 after Life Safety survey of affected areas beginning at 3:30 PM. The facility immediately initiated corrective action by discontinuing use of affected areas, training of staff, and ensuring that existing fire protection systems are not affected by on-going renovations. The facility corrective action verified on-site on July 29, 2016 at approximately 3:30 PM, included the erection of dust barriers, discontinuing use of areas creating excessive travel distances throughout the hospital affected areas.

Immediate Jeopardy was abated on August 3, 2016 when the facility provided and implemented an acceptable credible allegation of compliance.

On July 28, 2016 at approximately 3:30 PM, upon entry to the facility by the LSC Surveyor, based on observations, review of available drawings, interviews with President and CEO, VP Administration/General Counsel, and VP Operations on July 28, 2016 at approximately 3:30 PM onward, the facility failed to maintain the required means of egress/exits. Five required exits being rendered unusable due to new construction at the lobby level exit discharge to the former parking area. The Northwest Egress stairwell, designed to provide an alternate exit for floors 600, 500, 400, and 300 levels was observed discharging through a construction zone and terminating at a scaffolding stair designed for construction workers using protective equipment. The scaffold stair did not conform to minimum design requirements for exit stairs, and was an alternate exit for balcony behind operating room suite. The required exits were taken out of service on January 12, 2016 according to document provided by hospital administration - identified as Incident Command Report dated July 28, 2016. The Administrative Staff was informed of the non-compliance (Immediate Jeopardy) On July 28, 2016 at approximately 3:30 PM, the President/CEO, VP Administration/Legal Counsel, and VP Operations were notified that lack of a code compliant alternate exit in referenced areas is not compliant with the Life Safety Code which potentially affects the hospital condition of participation under CMS guidelines. The administration immediately implemented action to discontinue use of affected zones throughout the hospital. The facility immediately initiated corrective action by discontinuing use of affected areas, training of staff, and ensuring that existing fire protection systems are not affected by on-going renovations. The facility corrective action verified on-site on July 29, 2016 at approximately 3:30 PM, included the erection of dust barriers, discontinuing use of areas creating excessive travel distances throughout the hospital affected areas.

Immediate Jeopardy was abated on August 3, 2016 when the facility provided and implemented an acceptable credible allegation of compliance.

~ cross refer to NFPA 101 Life Safety Code Standard - Tag K 038