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Based on random observation during the survey walk-through and staff interview, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

A. Corrected 08/25/11.

B. Corrected 10/22/10.

C. Corrected 10/22/10

D. The north egress path for the Kitchen was observed to pass through a hazardous area (the Loading Dock) as prohibited by 7.5.2.1.

NEW 08/25/11: Carts, pallets, and other items were obsered being stored in the newly created corrridor as prohibited by 7.1.10.2.1.

E. Corrected 10/22/10


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Based on document review, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2.

Findings include:

A. Based on document review, fire drills are not conducted at varying times as required by 19.7.1.2. During the calendar year 2009, fire drills for the following quarters/shifts were conducted at the similar times listed:

1. Second Shift:

a. March 18, 2009: 4:00 PM.

b. May 19, 2009: 3:45 PM.

c. July 22, 2009: 3:45 PM.

d. November 18, 2009: 3:45 PM.

2. Third Shift:
a. February 24, 2009: 6:30 AM.

b. June 25, 2009: 6:30 AM.

c. September 22, 2009: 6:30 AM.

d. December 17, 2009: 6:30 AM.


UPDATE 10/22/10: Most tests are being conducted within 1-2 hour time frame per shift. A greater time variance is requested.

NEW 08/25/11. During the review of fire drill records on the morning of August 28, 2011, it was determined that the times at which fire drills are conducted during the second and third shifts do not suffuciently vary. According to hospital records, fire drills were conducted in calendar years 2010 and 2011 at the following times:
1. Second Shift:

a. January 26, 2010: 3:45 PM.

b. June 29, 2010: 4:00 PM.

c. August 12, 2010: 3:45 PM.

d. August 24, 2010: 4:00 PM.

e. October 13, 2010: 3:45 PM.

f. November 17, 2010: 4:45 PM.

g. January 6, 2011: 4:20 PM.

h. April 4, 2011: 5:30 PM.

2. Third Shift:

a. February 18, 2010: 6:30 AM.

b. April 21, 2010: 6:30 AM.

c. September 30, 2010: 6:40 AM.

d. No Fourth Quarter fire drill.

e. February 9, 2011: 6:45 AM.

f. May 11, 2011: 6:30 AM.

g. July 8, 2011: 6:45 AM.

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Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3.

Findings include:

A. Carts and equipment were observed in exit access corridors that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1. Locations and items observed include:

1. Corrected 08/25/11.
2. Third Floor:

a. ICU Corridor, scale.

NEW 08/25/11: The scale was observed in the same location.

b. Corrected 08/25/11.
3. Second Floor Phase I Wing:

a. Work stations on wheels placed in Alcoves serving Patient Sleeping Rooms.

NEW 08/25/11: The same condition was observed.

b. Corrected 08/25/11.

4. First Floor:

a. Corrected 08/25/11.

b. Carts and equipment in Exit Passageway immediately east of Surgical Department.

NEW 08/25/11: A linen cart and a wheeled cart were observed at the south end of this corridor.

c. Corrected 10/22/10

d. Corrected 10/22/10

e. Corrected 10/22/10

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Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

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