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Based on observations as referenced in the Life Safety report of survey completed September 13, 2016 through September 14, 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 as referenced in the Life Safety report of survey completed September 13, 2016 through September 14, 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:

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 as referenced in the Life Safety report of survey completed September 13, 2016 through September 14, 2016, the hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association.

The findings include:

A) Based on observations, on September 13 - 14, 2016 at approximately 1:30 PM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The soiled linen room near patient room 112 in the behavioral health area has an unsealed penetration in the rated ceiling above the ceiling tile.

2. The social workers office near patient room 112 in the behavioral health area has an unsealed penetration in the rated ceiling above the ceiling tile near the light fixture.

3. The soiled utility room has an unsealed penetration in the wall in the back of the room past the soffit in the ICU unit.

NFPA 101, 19.1.6.2; 8.2.3.2.4.2*
This deficiency affected one of two smoke compartments in each of the areas mentioned.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to Life Safety Code Standard - NFPA 101, Tag K 0012.

B) Based on observations, on September 13 - 14, 2016 at approximately 1:30 PM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Corridor wall is not complete to the underside of the deck - located above ceiling near MRI-Suite on first floor.

2. Pass-through window at first floor medical records area is not smoke tight; and is not designed to maintain required fire resistance rating of corridor wall and openings in buildings not equipped with a complete automatic sprinkler system.

3. Sheet metal cover, with barrel bolt latches, is not designed to maintain required fire resistance rating of corridor wall penetration in pharmacy pass-through window. Pharmacy is located on first floor.

NFPA 101, 19.3.6.1, 19.3.6.2, 19.3.6.4, 19.3.6.5
This deficiency affected one of two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to Life Safety Code Standard - NFPA 101, Tag K 0017.

C) Based on observations, on September 13 - 14, 2016 at approximately 1:30 PM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Door to social work office is equipped with a roller latch - room is located in the Behavioral Health Unit near room 122.

2. Positive latching hardware is not functioning on door to dayroom - located beside room 123 in the Behavioral Health Unit.

NFPA 101, 19.3.6.3
This deficiency affected one of two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to Life Safety Code Standard - NFPA 101, Tag K 0018.

D) Based on observations, on September 13 - 14, 2016 at approximately 1:30 PM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Cross corridor doors are equipped with electromagnetic locking device; the locking arrangement is not equipped with delayed feature and the facility is not equipped with a complete automatic sprinkler system or a complete detection system. Lock is located on cross corridor door between second floor elevator and OR Suite nurse's station.

NFPA 101, 19.2.4.1, 19.2.4.2, 7.2.1.6.1
This deficiency affected one of two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to Life Safety Code Standard - NFPA 101, Tag K 0032.

E) Based on observations, on September 13 - 14, 2016 at approximately 1:30 PM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Exit discharge doors to loading dock area require greater than a single hand motion to open a pair of doors to achieve required exit width - one door leaf is less than thirty-two inches width - doors are located on the first floor near materials management.

NFPA 101, 19.2.3.5, 7.2.1.5.4
This deficiency affected one of two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to Life Safety Code Standard - NFPA 101, Tag K 0040.

F) Based on observations, on September 13 - 14, 2016 at approximately 1:30 PM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Cross corridor door area is not equipped with exit sign at time of survey. Doors are located between second floor elevator and OR Suite nurse's station.

NFPA 101, 19.2.10.1
This deficiency affected one of two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to Life Safety Code Standard - NFPA 101, Tag K 0047.

G) Based on observations, on September 13 - 14, 2016 at approximately 1:30 PM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

The strobe light is not functioning for the audible/visual signaling device in the materials management area - located on the first floor.

NFPA 101, 9.6.1.7, 9.6.1.4, NFPA 72
This deficiency affected one of two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to Life Safety Code Standard - NFPA 101, Tag K 0052.

H) Based on observations, on September 13 - 14, 2016 at approximately 1:30 PM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The emergency exit discharge lighting serving Behavioral Health, Outpatient Pain Center, and area near green canopy are not equipped with lighting connected to the Life Safety Branch of the essential electrical system.

2. Remote emergency stop switch for generator is mounted to the generator exterior housing and not located remote from generator.

3. There is no low fuel indicator to monitor fuel level in main fuel tank for the emergency generator. Generator annunciator shall function when the main fuel storage tank contains less than a 3-hour operating supply.(NFPA 99, Section 3-4.1.1.15)

NFPA 101, NFPA 99, Sections 3-4.2.2.2, 3-5.2.2
This deficiency potentially affects all smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to Life Safety Code Standard - NFPA 101, Tag K 0145.

I) Based on observations, on September 13 - 14, 2016 at approximately 1:30 PM onward, the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. Electrical junction box with wires and terminal connectors is not equipped with a junction box cover - box is located on exterior wall of outpatient pain center exit discharge.

2. Room air conditioners in the following areas are not equipped with single use circuit and receptacles in accordance with manufacturer's listing:

a. LTAC Administration Offices

3. An electrical junction box with wires and terminal connectors is not equipped with a junction box cover. The box is located in the behavioral health unit above the ceiling above the ceiling tile near the staff lounge.

NFPA 101, 19.9.1, 9.1.2
This deficiency affected one of two smoke compartments.
Failure to comply with minimum standards as referenced increases the risk of death or injury due to fire and/or smoke.

~ cross refer to Life Safety Code Standard - NFPA 101, Tag K 0147.

Based on policy review, personnel file review, observation and staff interview, the facility staff failed to prevent cross contamination in 1 of 2 observations of staff interactions with patients on contact precautions (Staff #1, Patient #30), and failed to follow policy for air drying dishes.
The findings include:
1. Review of the facility's policy "ISOLATION PRECAUTIONS" (revised 11/2015), revealed "... Contact Precautions are indicated for patients who are known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the patient or indirect contact with environmental surfaces or patient care items in the patient's environment... Indicated when *Lab result indicates presence of MRSA... Personal Protective Equipment (PPE)... *Gloves are worn to enter patient room *Gown is worn to enter patient room..."
Review of Staff #1's personnel file revealed completed education included "PPE" on 07/13/2016 and in Infection Prevention on 07/11/2016.
Review on 09/15/2016 of Patient #30's open medical record revealed the patient was admitted through the Emergency Department on 09/10/2016. Review revealed a "MRSA Nares" (test for MRSA [methicillin resistant staphylococcus aureus] by swabbing the nares) was completed on admission along with a physician's order for contact precautions at 0042. Continued review revealed the MRSA Nares result was positive on 09/10/2016 at 0026.
Observation on 09/15/2016 at 0930 in the Intensive Care Unit (ICU) revealed staff #1 in room #295 standing next to the bedside table at the foot of the bed, conversing with Patient #30, who was in a sitting position. Observation revealed the employee handed the patient something prior to leaving the room. Observation revealed Personal Protective Equipment (PPE) hanging from the door of the room and a sign indicating the patient was on contact precautions. Observation revealed the employee was not wearing any type of PPE. Observation revealed the employee sanitized her bare hands upon leaving the patient's room.
Interview with Staff #1 immediately after the observation revealed "We can stay behind the line if we don't dress up... I was going to stay against the wall and ended up handing him something... I should have dressed out."
Interview with the ICU Nurse Manager on 09/15/2016 at 0938 revealed when a patient in the ICU was on contact precautions, staff could not go "past the doorway" without donning PPE. "In the ICU, you have to stand at the door... On the Medical Floor we have a safe zone tiled out and clearly marked." Interview revealed there was no designated line for a safe zone in the ICU. Interview revealed the expectation was for staff to wear a gown and gloves while in an ICU room with a patient on contact precautions. Continued interview revealed Patient #30 was a "frequent flyer" (a patient who has been a patient several times before, and with whom the staff is familiar) and tested positive for MRSA on previous admissions. The interview revealed Staff #1 should have worn PPE since she was past the doorway in the patient's room. The interview confirmed the observation finding.



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2. Review of facility policy "Department of Infection Prevention: Dietary Department," with revision date of 5/2016, revealed "...3. Approved Sanitizing Methods ... 1. ...Allow pots or utensils to air dry. ..."
Observation on 09/14/2016 at 1100 in the dishwashing room revealed clean dishes covered with droplets of water arranged on a drying table. Further observation revealed a working fan mounted to the side of the wall directed toward the dishes.
Interview on 09/14/2016 at 1100 with the dietary supervisor revealed the fan has always been there.
Interview on 09/15/2016 at 1405 with the infection control nurse revealed a fan blowing on the dishes is not best practice. Further interview revealed infection control nurse rounds are not made in the kitchen area.
Observation on 09/15/2016 at 1500 in the dishwashing room revealed the fan had been removed from the wall.
Interview on 09/15/2016 at 1500 with the dietary supervisor revealed the fan was removed and would not be returned to the wall.