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UNIVERSITY OF WI HOSPITALS & CLINICS AUTHORITY
PHYSICAL ENVIRONMENT
Tag No.: A0700
Based on observation, staff interviews and review of maintenance documents, the facility did not construct and maintain the building systems to ensure a safe physical environment due to the cumulative effects of environment deficiencies and resulted in the hospital's inability to ensure a safe environment for all patients.
FINDINGS INCLUDE:
1. In the Clinical Sciences Center portion of UW Hospital surveyor #14105 observed that the facility had the following uncorrected deficiencies: K11-Separation Walls, K15-Finishes, K17-Corridor Walls, K29-Hazardous Rooms, K52-Fire Alarm Inspections, K67-Ventilation, K77-Medical Gas Piping, K130-Miscellaneous.
2. In the American Family Children's Hospital portion of UW Hospital surveyor #14105 observed that the facility had the following uncorrected deficiencies: K17-Corridor Walls, K18-Corridor Doors, K20-Vertical Openings, K27-Smoke Barrier Doors, K29-Hazardous Rooms, K38-Egress, K51-Fire Alarm Installation, K56-Sprinkler Installation, K130-Miscellaneous, and K211-Alcohol Based Hand Rubs.
3. In the Orthotics Clinic outpatient portion of UW Hospital, surveyor #14105 that the facility had the following uncorrected deficiency: K130-Miscellaneous.
4. In the University Station outpatient portion of UW Hospital, surveyor #14105 observed that the facility had the following uncorrected: K130-Miscellaneous.
Please refer to the full description of the deficient practices at the cited K-tags in the appropriate building. This observed situation was not compliant with CFR 482.41.
LIFE SAFETY FROM FIRE
Tag No.: A0709
Based on observation, staff interviews and review of maintenance documents, the facility did not construct and maintain the building systems to ensure a safe physical environment due to the cumulative effects of environment deficiencies and resulted in the hospital's inability to ensure a safe environment for all patients.
FINDINGS INCLUDE:
1. In the Clinical Sciences Center portion of UW Hospital surveyor #14105 observed that the facility had the following uncorrected deficiencies: K11-Separation Walls, K15-Finishes, K17-Corridor Walls, K29-Hazardous Rooms, K52-Fire Alarm Inspections, K67-Ventilation, K77-Medical Gas Piping, K130-Miscellaneous.
2. In the American Family Children's Hospital portion of UW Hospital surveyor #14105 observed that the facility had the following uncorrected deficiencies: K17-Corridor Walls, K18-Corridor Doors, K20-Vertical Openings, K27-Smoke Barrier Doors, K29-Hazardous Rooms, K38-Egress, K51-Fire Alarm Installation, K56-Sprinkler Installation, K130-Miscellaneous, and K211-Alcohol Based Hand Rubs.
3. In the Orthotics Clinic outpatient portion of UW Hospital, surveyor #14105 that the facility had the following uncorrected deficiency: K130-Miscellaneous.
4. In the University Station outpatient portion of UW Hospital, surveyor #14105 observed that the facility had the following uncorrected: K130-Miscellaneous.
Please refer to the full description of the deficient practices at the cited K-tags in the appropriate building. This observed situation was not compliant with CFR 482.41.