39323 Based on observations, the facility failed to maintain the building construction. The findings included: Observations on 11/04/2019 between 11:20 AM - 3:14 PM, revealed the ceilings throughout the facility were not according to the buildings plans. Tiles throughout the facility have been altered and changed, not maintaining a 1 hour barrier. NFPA 101, 19.1.6.1 (2012 Edition) NFPA 101, 8.2.3 (2012 Edition) The VP of operations and maintenance director were present when this deficiency was identified, and was later acknowledged during the exit conference on 11/04/2019.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39323 Based on observations, the facility failed to maintain the stairways. The findings included: 1. Observations on 11/04/2019 at 11:20 AM, revealed the following deficiencies above the ceiling outside of the 3rd floor stair b on the rated fire/smoke barrier wall: a. Steel joists not sealed b. Grout falling between the concrete c. 1 + inch conduit with the fire stop falling through NFPA 101, 8.3.5.1 (2012 Edition) 2. Observations on 11/04/2019 at 12:23 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier, outside of the stairwell shaft by room [ROOM NUMBER]: a. + conduit and + flex in the same penetration not properly sealed b. Left side bottom of beam is unsealed c. Right side of beam not sealed properly (fire stop is falling out) NFPA 101, 8.3.5.1 (2012 Edition) 3. Observations on 11/04/2019 at 12:27 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier, inside of the stairwell shaft by room [ROOM NUMBER]: a. Unsealed at the deck b. Steel trusses not properly sealed NFPA 101, 8.3.5.1 (2012 Edition) 4. Observations on 11/04/2019 at 12:32 PM, revealed the following deficiencies above the ceiling on the rated masonry fire/smoke barrier, outside of the stairwell by registration (on the 2nd floor): a. 10 x 4 inch improper sheetrock repair on the L side of beam b. + inch copper lines unsealed c. Steel trusses unsealed in the middle NFPA 101, 8.3.5.1 (2012 Edition) 5. Observations on 11/04/2019 at 1:04 PM, revealed the bottom right side of a beam unsealed outside of the stairs by the admin office above the ceiling, on the rated fire/smoke barrier wall. NFPA 101, 8.3.5.1 (2012 Edition) The VP of operations and maintenance were present when these deficiencies were identified, and were later acknowledged during the exit conference on 11/04/2019.

39323 Based on observations, the facility failed to maintain the hazardous areas. The finding included: Observations on 11/04/2019 at 1:42 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier wall outside of the facility engineer/powerhouse room: a. Joint tape peeling at the deck b. Trusses not sealed c. Mixed fire stop around 3 inch metal sleeve with a copper line NFPA 101, 8.3.5.1 (2012 Edition) The VP of operations and maintenance were present when these deficiencies were identified, and were later acknowledged during the exit conference on 11/04/2019.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39323 Based on observations, the facility failed to maintain the fire alarm system. The finding included: Observation on 11/04/2019 at 2:47 PM, revealed a smoke detector to close to airflow in the corridor outside of room [ROOM NUMBER]. NFPA 101, 19.3.4.1 (2012 Edition), NFPA 101, 9.6.1.3 (2012 Edition) NFPA 72, 17.7.4.1 (2010 Edition) The VP of operations was present when this deficiency was identified, and was later acknowledged during the exit conference on 11/04/2019.

39323 Based on document review, the facility failed to maintain the sprinkler system. The findings included: Document review on 11/04/2019 at 12:13 PM, revealed the facility failed to provide documentation of a 5 year internal obstruction inspection. The last one was dated 11/07/2010. NFPA 101, 19.3.5.1 (2012 Edition), NFPA 101, 9.7.5 (2012 Edition) NFPA 25, 14.2.1 (2011 Edition) The VP of operations was present when this deficiency was identified, and was later acknowledged during the exit conference on 11/04/2019.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39323 Based on observations, the facility failed to maintain the smoke barriers. The findings included: 1. Observations on 11/04/2019 at 11:22 AM, revealed the following deficiencies above the ceiling inside of the materials/pharmacy room on the rated fire/smoke barrier wall: a. Fire stop was cracking at the head of wall b. + inch conduit with wires not sealed c. Bar joists were unsealed d. Bar joists not sealed properly (sheetrock mud) e. + inch conduit not sealed properly (sheetrock mud) NFPA 101, 8.3.5.1 (2012 Edition) 2. Observations on 11/04/2019 at 11:32 AM, revealed the following deficiencies above the ceiling inside of the classroom on the rated fire/smoke barrier wall: a. Bar joists not sealed on the top and bottom throughout b. Head of wall fire stop was cracking NFPA 101, 8.3.5.1 (2012 Edition) 3. Observations on 11/04/2019 at 11:38 AM, revealed the following deficiencies above the ceiling outside of room [ROOM NUMBER] on the rated fire/smoke barrier: a. + inch conduits not properly sealed b. Water lines not properly sealed c. Cables with mixed fire stop d. Insulated water lines with mixed fire stop e. Head of wall not sealed correctly above HVAC duct NFPA 101, 8.3.5.1 (2012 Edition) 4. Observations on 11/04/2019 at 11:51 AM, revealed the following deficiencies above the ceiling on the 2 hour rated fire/smoke barrier walls in the housekeeping room: a. Not sealed at the deck b. Steel trusses not sealed c. + inch conduits not sealed in the wall d. (3) 3 inch pipes not sealed in the wall NFPA 101, 8.3.5.1 (2012 Edition) 5. Observations on 11/04/2019 at 11:53 AM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier wall outside of the housekeeping room: a. 5 inch insulated pipe with sheetrock loose b. 1 cable sealed with sheetrock mud NFPA 101, 8.3.5.1 (2012 Edition) 6. Observations on 11/04/2019 at 11:55 AM, revealed 2 steel trusses penetrating the elevator shaft wall that were not sealed by the nurses station. NFPA 101, 8.3.5.1 (2012 Edition) 7. Observations on 11/04/2019 at 12:03 PM, revealed the following deficiencies on the rated fire/smoke barrier wall inside of central supply: a. Bar joists not sealed properly b. 3 inch insulated water line not properly sealed c. Head of wall in the med room not properly sealed (mixed fire stop) d. Wires throughout not properly sealed (mixed fire stop) NFPA 101, 8.3.5.1 (2012 Edition) 8. Observations on 11/04/2019 at 12:10 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier, at the nurses station: a. Mixed fire stop at the head of wall b. + conduit with mixed fire stop c. 1 bar joist not sealed NFPA 101, 8.3.5.1 (2012 Edition) 9. Observations on 11/04/2019 at 12:11 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier, above the medication prep room: a. 1 inch copper lines not sealed b. Sanitary pipe not sealed c. Bar joists not sealed NFPA 101, 8.3.5.1 (2012 Edition) 10. Observations on 11/04/2019 at 12:13 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier, in the medication prep room: a. + inch conduits not properly sealed b. 2 inch sprinkler pipe not properly sealed c. 1 inch insulated pipes not properly sealed d. 7 x 7 inch improper sheetrock repair below the HVAC duct work NFPA 101, 8.3.5.1 (2012 Edition) 11. Observations on 11/04/2019 at 12:18 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier, inside of the soiled room by the nurses station: a. 4 x 4 inch improper sheetrock repair by flex conduit b. Steel [NAME] not sealed c. Sheetrock damage around + inch fire alarm conduit d. Sheetrock damage at the bottom right of HVAC duct e. Sprinkler unsealed on side wall f. Head of wall unsealed g. Mixed fire stop throughout the room NFPA 101, 8.3.5.1 (2012 Edition) 12. Observations on 11/04/2019 at 12:40 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier, inside of the lab: a. Mixed fire stop around tresses throughout the lab area b. + inch flex from junction box not properly sealed c. 5 insulated pipes from + inch to 1 inch unsealed d. 3 x 3 inch improper sheetrock repair over the bulletin board e. Steel trusses not properly sealed NFPA 101, 8.3.5.1 (2012 Edition) 13. Observations on 11/04/2019 at 12:45 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier, inside of the lab break room: a. Mixed fire stop around steel trusses b. Mixed fire stop at the deck c. (4) + inch copper lines over refrigerator with mixed firestop d. Mixed fire stop around conduit above the evacuation plan NFPA 101, 8.3.5.1 (2012 Edition) 14. Observations on 11/04/2019 at 12:50 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier, outside of the lab break room: a. Mixed firestop around steel trusses b. Penetration over door with mixed fire stop (putty with caulk) c. Fire alarm conduit sealed on the right or bottom side d. Insulated pipes not properly sealed e. Steel trusses throughout the corridor of the lab f. Mixed firestop at the deck throughout the corridor of the lab NFPA 101, 8.3.5.1 (2012 Edition) 15. Observations on 11/04/2019 at 12:55 PM, revealed the unsealed steel trusses above the ceiling on the rated fire/smoke barrier, outside of the 2nd floor elevator. NFPA 101, 8.3.5.1 (2012 Edition) 16. Observations on 11/04/2019 at 12:57 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier, outside of the lab (by the vending machines): a. Mixed fire stop around insulated pipes b. Deck improperly sealed c. 12 foot x 18 foot improper sheetrock repair NFPA 101, 8.3.5.1 (2012 Edition) 17. Observations on 11/04/2019 at 1:06 PM, revealed the steel trusses by the CT elevators on the 1st floor were not correctly sealed, above the ceiling on the rated fire/smoke barrier wall. NFPA 101, 8.3.5.1 (2012 Edition) 18. Observations on 11/04/2019 at 1:11 PM, revealed a + inch conduit not properly sealed, above the ceiling on the masonry rated fire/smoke barrier wall in the ER storage room. NFPA 101, 8.3.5.1 (2012 Edition) 19. Observations on 11/04/2019 at 1:13 PM, revealed the top of a beam at the deck was not sealed, above the ceiling on the rated fire/smoke barrier wall on the back wall of ER 6 and the ER 6 restroom. NFPA 101, 8.3.5.1 (2012 Edition) 20. Observations on 11/04/2019 at 1:18 PM, revealed the following deficiencies, above the ceiling on the rated fire/smoke barrier wall outside of the ER biohazard room: a. Deck not properly sealed b. Electrical conduits not properly sealed c. 4 inch metal sleeve below HVAC not sealed d. 2 inch metal sleeves not sealed NFPA 101, 8.3.5.1 (2012 Edition) 21. Observations on 11/04/2019 at 1:21 PM, revealed the following deficiencies, above the ceiling on the rated fire/smoke barrier wall inside of the ER biohazard room: a. Bar joist not sealed b. HVAC duct not properly sealed c. Metal stud at a 45 degree angle into the wall not properly sealed d. Insulated pipes with mixed firestop/sheetrock mud e. Multiple improper sheetrock repairs f. Improper firestop/penetrations unsealed throughout the room NFPA 101, 8.3.5.1 (2012 Edition) 22. Observations on 11/04/2019 at 1:26 PM, revealed the following deficiencies, above the ceiling on the rated fire/smoke barrier wall in room [ROOM NUMBER]: a. Unsealed 4 inch x 4 inch penetration b. + inch flex not properly sealed c. 1 inch line unsealed d. + inch copper line unsealed e. Top of beam unsealed across the wall NFPA 101, 8.3.5.1 (2012 Edition) 23. Observations on 11/04/2019 at 1:31 PM, revealed the following deficiencies, above the ceiling on the rated fire/smoke barrier wall outside of the procedure break hall: a. Top of beam unsealed b. 1 inch copper pipe with single wire not properly sealed c. 5 inch metal sleeve not sealed NFPA 101, 8.3.5.1 (2012 Edition) 24. Observations on 11/04/2019 at 1:34 PM, revealed the following deficiencies, above the ceiling on the rated fire/smoke barrier wall in the women's locker room: a. Galvanized sprinkler improperly sealed b. All thread hangar tapped c. + conduit through wall not properly sealed NFPA 101, 8.3.5.1 (2012 Edition) 25. Observations on 11/04/2019 at 1:39 PM, revealed the following deficiencies, above the ceiling on the rated fire/smoke barrier wall, above the cross corridor doors outside of the kitchen: a. + inch fire alarm conduit with mixed fire stop b. Smooth conduit not properly sealed c. 2 inch insulated lines not properly sealed d. + inch lines not properly sealed e. Putty mixed with caulk in conduits f. Flex conduit not properly sealed on the right side g. 10 inch water return lines not properly sealed NFPA 101, 8.3.5.1 (2012 Edition) 26. Observations on 11/04/2019 at 1:40 PM, revealed multiple penetrations (trusses, smooth conduits, copper lines, etc) sealed with sheetrock mud and not fire stop, above the ceiling on the rated fire/smoke barrier wall outside of the kitchen (across from panels labeled D) NFPA 101, 8.3.5.1 (2012 Edition) 27. Observations on 11/04/2019 at 1:42 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier wall outside of the facility engineer/powerhouse room: a. Joint tape peeling at the deck b. Trusses not sealed c. Mixed fire stop around 3 inch metal sleeve with a copper line NFPA 101, 8.3.5.1 (2012 Edition) 28. Observations on 11/04/2019 at 1:46 PM, revealed the following deficiencies above the ceiling on the rated fire/smoke barrier wall outside of the PT access manager office: a. Insulated pipe that 45 degree angles into the wall not properly sealed b. 2 insulated pipes not sealed properly c. Mixed fire stop around multiple conduits and pipes d. Steel trusses not sealed e. 12 inch by 12 inch Improper sheetrock repair above the restroom vestibule door f. Multiple conduits throughout have sheetrock mud mixed with fire stop NFPA 101, 8.3.5.1 (2012 Edition) 29. Observations on 11/04/2019 at 1:48 PM, revealed the following deficiencies above the ceiling on the 2 hour rated fire/smoke barrier wall outside of the engineers door: a. Multiple conduits throughout have mixed fire stop b. Steel trusses not sealed in the middle c. 1 + inch PVC with sheetrock mud (between engineer and electric panel) d. 3 inch sprinkler line with mixed fire stop e. Hot water return line and supply line mixed fire stop NFPA 101, 8.3.5.1 (2012 Edition) 30. Observations on 11/04/2019 at 1:46 PM, revealed the following deficiencies above the ceiling on the 2 hour rated fire/smoke barrier wall outside of the kitchen: a. 4 insulated water lines not sealed on the top and mixed fire stop on the bottom b. 1/4 inch Fire alarm conduit unsealed on the bottom c. Bottom of structural beam mixed fire stop/not properly sealed NFPA 101, 8.3.5.1 (2012 Edition) 31. Observations on 11/04/2019 at 2:55 PM, revealed the following deficiencies in the IT room on the rated fire/smoke barrier wall: a. + inch conduits with mixed fire stop b. 2 flex conduits with improper fire stop (sheetrock mud) over the radios NFPA 101, 8.3.5.1 (2012 Edition) The VP of operations and maintenance were present when these deficiencies were identified, and were later acknowledged during the exit conference on 11/07/2019.

16579 Based on policy review, document review, medical record review and interview, it was determined the hospital failed to ensure all patients presenting to the Emergency Department (ED) seeking medical care received a medical screening examination (MSE) to determine if an emergency medical condition existed for 1 of 1 (Patient #15) sampled patients who was refused care by the hospital. Refer to findings in deficiency A2406.

16579 Based on policy review, document review, medical record review and interview, it was determined the hospital failed to ensure all patients presenting to the Emergency Department (ED) seeking medical care received a medical screening examination (MSE) to determine if an emergency medical condition existed for 1 of 1 (Patient #15) sampled patients who was refused care by the hospital The findings included: 1. Review of the hospital's MEDICAL STAFF RULES AND REGULATIONS revealed, .Medical Screening Exam: 1. Federal and State laws and regulations provide that any individual who comes to the Hospital property or premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination performed by individuals qualified to perform such examination to determine whether or not an emergency medical condition exists. An appropriate Medical Screening Examination includes routinely available ancillary services. A Medical Screening Examination shall be provided to determine whether an emergency medical condition exists or, with respect to a pregnant woman having contractions, whether the woman is in labor. This medical screening examination must be provided to all individuals regardless of diagnosis, race, age, creed, sex, handicap, sexual preferences, national origin or financial status. 2. No delay to a medical screening examination or stabilizing treatment shall occur due to inquiries as to method of payment or insurance status. An appropriate Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition exists or a woman is in labor. Such screening must be done within the facility's capability and available personnel, including on-call physicians. The medical screening examination is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized or appropriately transferred . 2. Review of the hospital's Emergency Department (ED) Central Log dated 2/3/15 revealed Patient #15 arrived at 8:30 PM. The entry documented the reason for the visit, FALL: 30 WEEKS PREGNANT. The disposition category documented, Was Refused Treatment. The disposition type/disposition plan documented, AGAINST MEDICAL ADVICE Left Prior to Med Screen. 3. Review of the EMERGENCY PATIENT RECORD for Patient #15 revealed arrival date/time as 2/3/15 at 8:30 PM. The stated complaint was documented as fall; 30 weeks pregnant. The chief complaint was documented as Hip/pelvis. The assessment section of the EMERGENCY PATIENT RECORD documented the disposition category: Was Refused Treatment. The Other Notes section of the EMERGENCY PATIENT RECORD documented an entry dated 2/9/15 11:22 AM PT. LEFT THE EMERGENCY DEPARTMENT WITHOUT BEING ASKED TO SIGN IN, OR PROVIDING ANY PERSONAL INFORMATION. 4. During an interview in the conference room on 2/12/15 at 9:22 AM the Emergency Department Nurse Manager (EDNM) stated Patient #15's father called her on 2/4/15 to report an incident that occurred 2/3/15. Patient #15 had come to the Emergency Department to have an ultrasound after falling in the shower. He stated his daughter was 30 weeks pregnant. Patient #15's father stated the patient was unable to receive an ultrasound, and they left the building. 5. During an interview in the conference room on 2/12/15 at 9:22 AM the EDNM stated she spoke with Patient #15 about the incident. The EDNM stated Patient #15 told her she came into the ED and asked the SecurityOfficer #1 if the hospital did ultrasounds. The EDNM stated Patient #15 said the Security Officer went to talk with staff, came back to the desk and told her they were unable to do ultrasounds at night. 6. During a telephone interview in the conference room on 2/12/15 at 10:45 AM, Security Officer #1 stated Patient #15 came into the ED 2/3/15 between 8:00 PM and 8:30 PM. Security Officer #1 stated the patient said she was 30 weeks pregnant and had fallen in the shower and needed an ultrasound. Security Officer #1 stated Patient #15 said she did not want to be seen (by a physician), she wanted an ultrasound. Security Officer #1 stated he verified with nurses and Physician #1 ultrasounds were not performed after 7:00 PM at night. The Security Officer stated when he told Patient #15 this, she and the gentleman with her, left the building. 7. During a telephone interview in the conference room on 2/12/15 at 2:05 PM, Physician #1 stated Patient #15 came into the ED and asked for an ultrasound. Physician #1 stated the hospital did not do ultrasounds at night. Physician #1 stated he saw the patient on video camera leaving the ED. Physician #1 stated Patient #15 left the building, her question was answered, . don't do ultrasounds at night . Physician #1 stated he thought it was Patient #15's choice to leave. 8. During an interview in the conference room on 2/12/15 at 2:32 PM, Registered Nurse (RN) #1 stated on 2/3/15 the Security Officer walked back to the ED wanting to know if a patient could have an ultrasound that night. RN #1 stated she and the physician stated the ultrasound could not be done tonight. She stated if a patient came in after 7:00 PM and needed an ultrasound, they would have to go somewhere else. 9. During a telephone interview in the conference room on 2/12/15 at 3:00 PM, RN #2 stated the Security Officer came to the back of the ED to question if we had ultrasound at night and we (RN #1, 2 and Physician #1)told him no. RN #2 stated when the Security Guard asked about an ultrasound, she got the impression he was just asking a question. She stated she did not get the impression anyone needed to be seen. 10. Review of training documentation and interviews for verification revealed corrective actions initiated included Security Officer #1 completed a web-based EMTALA training on 2/9/15 and informed of the rearrangement of personnel at the front desk so that Security is now located at a desk in the back of the reception area with video monitors, radios and ear buds for communication. The two RN's involved [RN # 1 & #2] completed the web-based EMTALA training and both will receive written Corrective Actions for failure to respond to a clinical request of an individual that presented to a dedicated emergency department. During an interview in the Administrative Conference Room on 2/12/15 at 2:45 PM, the [NAME] President of Quality and Risk Management stated, I will be meeting with the CMO [Chief Medical Officer] tomorrow and the CMO will do a collegial conversation with [Physician #1] to emphasize the importance of being more patient focus instead of service provider. The Director of Ethics and Compliance stated that EMTALA training will be done system-wide quarterly instead of the current, annually with emphasis on Security personnel and a portion of the EMTALA regulations will be discussed each month at the Security staff.