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Based on observation, the facility failed to ensure that one pathway to an exit discharge had required signage.

Findings include:

On 3/11/14 at 9:53 AM, on the first floor near the Administration Suite, exit marking signage directed occupants to only one path of travel, towards the main entrance to the facility. A shorter exit route was available through the passageway between the Hospital and the adjacent Medical Office Building (MOB). Access to the MOB exit discharge was not marked with egress signage.

NFPA 99 (2005 ed.), 9.4.1 Storage for nonflammable gases equal to or greater than 85 m3 (3,000 ft3) compressed shall comply with 5.1.3.3.2 and 5.1.3.3.3.
NFPA 99 (2005 ed.), 5.1.3.3.2(4) If indoors, be constructed and use interior finishes of noncombustible or limited-combustible materials such that all walls, floors, ceilings and doors are of minimum 1-hour fire resistance rating.

Based on observation, the facility failed to ensure that one medical gas storage room, containing greater than 3,000 cubic feet of oxidizing gases (oxygen and nitrous oxide), had noncombustible or limited-combustible interior finishes.

Findings include:

On 3/11/14 at 11:00 AM, in the first floor Oxygen Storage Room, the following oxidizing gasses were observed:
- six "H" sized cylinders of oxygen (1,686 cubic feet);
- 30 "E" sized cylinders of oxygen (750 cubic feet); and
- six "H" sized cylinders of nitrous oxide (1,686 cubic feet).

The total volume of oxidizing gases in this one storage room was approximately 4,122 cubic feet. The flooring material in this medical gas storage room was vinyl composition tile (VCT), a combustible material.

Based on observation, the facility failed to ensure that seven, Alcohol Based Hand Rub (ABHR) dispensers were installed a safe distance from electrical, ignition sources.

Findings include:

On 3/11/14 at 11:17 AM, on the first floor, Clean Linen Room, one ABHR was installed over a light switch.

On 3/12/14 at 11:00 AM, on the second floor, Case Manager's alcove, one ABHR was installed over a duplex, electrical receptacle.

On 3/12/14 at 11:40 AM, on the second floor, Intensive Care Unit's suite, four ABHR's were installed over electrical ignition sources:
- Room 2-ABHR over a night light;
- Room 3-ABHR over duplex electrical receptacle;
- Room 4-ABHR over night light; and
- Room 5-ABHR over a night light.

On 3/12/14 at 2:00 PM, on the first floor Surgical Suite's Operating Room #1, one ABHR was installed over a 4-plex electrical receptacle.

Based on observation, the facility failed to ensure that one pathway to an exit discharge had required signage.

Findings include:

On 3/11/14 at 9:53 AM, on the first floor near the Administration Suite, exit marking signage directed occupants to only one path of travel, towards the main entrance to the facility. A shorter exit route was available through the passageway between the Hospital and the adjacent Medical Office Building (MOB). Access to the MOB exit discharge was not marked with egress signage.

NFPA 99 (2005 ed.), 9.4.1 Storage for nonflammable gases equal to or greater than 85 m3 (3,000 ft3) compressed shall comply with 5.1.3.3.2 and 5.1.3.3.3.
NFPA 99 (2005 ed.), 5.1.3.3.2(4) If indoors, be constructed and use interior finishes of noncombustible or limited-combustible materials such that all walls, floors, ceilings and doors are of minimum 1-hour fire resistance rating.

Based on observation, the facility failed to ensure that one medical gas storage room, containing greater than 3,000 cubic feet of oxidizing gases (oxygen and nitrous oxide), had noncombustible or limited-combustible interior finishes.

Findings include:

On 3/11/14 at 11:00 AM, in the first floor Oxygen Storage Room, the following oxidizing gasses were observed:
- six "H" sized cylinders of oxygen (1,686 cubic feet);
- 30 "E" sized cylinders of oxygen (750 cubic feet); and
- six "H" sized cylinders of nitrous oxide (1,686 cubic feet).

The total volume of oxidizing gases in this one storage room was approximately 4,122 cubic feet. The flooring material in this medical gas storage room was vinyl composition tile (VCT), a combustible material.