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Based on staff interview and record review, the facility did not provide documentation to show that the Orthopedic Hospital of Wisconsin complied with all applicable Federal, State and local emergency preparedness requirements in accordance with 42 CFR section 482.15. The Orthopedic Hospital of Wisconsin must establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. This deficient practice could affect all patients and an undeterminable number of staff and visitors.

Findings include:
At 3:45 PM, on February 19, 2018, during an interview following the record review it was explained that the Orthopedic Hospital of Wisconsin specific to the facility under survey did not have a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The condition was confirmed at the time of discovery by a concurrent interview with the Administrator (A), Director of Facility Managment (F), Manager of Facility Managment (G) and Mechanic 3 (H).

Based on observation and interview, the facility did not provide and maintain a room for hazardous storage as required by NFPA 101 (2012 edition), 19.3.2.1, and 8.4 with doors that are self- closing or automatic closing. This deficiency had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 02/19/2018 at 2:12 pm, it was observed in the C smoke compartment on the second floor in OR 1 that the door would not self-close because there was no door closer, or coordinator on the inactive leaf. The room exceeded 50 sq. ft. and contained a quantity of stored combustible materials considered hazardous. The condition was confirmed at the time of discovery by a concurrent interview with staff G (Facilities Manager), staff F (Dir. Facilities Management), Staff H (Maintenance Mechanic 3), and Staff I (Maintenance Mechanic).

2. On 02/19/2018 at 2:28 pm, it was observed in the C smoke compartment on the second floor in the storage room, that the door would not self-close because there were (2) plastic bins that blocked the door and prevented it from closing. The room exceeded 50 sq. ft. and contained a quantity of stored combustible materials considered hazardous. The condition was confirmed at the time of discovery by a concurrent interview with staff G (Facilities Manager), staff F (Dir. Facilities Management), Staff H (Maintenance Mechanic 3), and Staff I (Maintenance Mechanic).

Based on observation, and interview, the facility did not have pull stations free of obstructions as required by NFPA 70, and NFPA 72. This deficiency had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 02/19/2018 at 3:22pm, it was observed in the B smoke compartment on the first floor in the entrance lobby that access to the manual pull station of the fire alarm system was obstructed and not accessible for operation. Wheel chairs were stored in front of the pull station. The condition was confirmed at the time of discovery by an interview with staff G (Facilities Manager), staff F (Dir. Facilities Management), Staff H (Maintenance Mechanic 3), and Staff J (Maintenance Mechanic).

Based on observation and interview, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have 2 spare sprinklers of each type as required by NFPA 101 (2012 edition), 9.7.5, and NFPA 25 (2011 edition). This deficiency had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 02/19/2018 at 3:05 pm, it was observed in the B smoke compartment on the first floor in the riser room that there was only 1 of each type of sprinkler head for a 200 degree side wall standard response sprinkler head with a green bulb. The condition was confirmed at the time of discovery by a concurrent interview with staff G (Facilities Manager), staff F (Dir. Facilities Management), Staff H (Maintenance Mechanic 3), and Staff I (Maintenance Mechanic).