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Based on observation of the physical environment and interview with facility staff it was determined that the facility staff failed to insure that there are readily visible "EXIT" signs indicating access to exits in all areas, thereby creating an unsafe condition.

The findings include:

1) During the complaint survey on December 17, 2013 at approximately 1145 hours it was observed and confirmed through interview with the Safety Director that in the North Hospital Building ground floor "Dental Clinic" a required second means of egress is not marked with "EXIT" signs as required.

The failure to designate and properly mark EXIT access and direction thereto has the potential to promote harm to occupants of the building in the event of a fire or other emergency.

Based on observation of the physical environment, interview with facility staff, and review of the facility's records it was determined that the facility staff failed to provide a safe and hazard free environment by not enforcing the facility smoking policy and/or maintaining a hazard free smoking area.

The findings include:

1) During the complaint survey on December 17, 2013 a copy of the facility smoking policy was requested and obtained for review by this surveyor (Policy #EOC-003, rev. 12/12). Information received from other survey team members related to the patient involved in the incident which prompted this complaint survey and was also reviewed. After reviewing all information related to the smoking policy of University of Maryland Medical Center as submitted per this request and information from survey team members, it was determined that:
a) Nursing staff did not adhere to their Responsibility in Policy #EOC-003 II.
b) Physician did not adhere to his/her Responsibility in Policy #EOC-003 II.
c) UMMC Employees did not adhere to their Responsibility in Policy #EOC-003 II.
d) Security Department personnel did not adhere to their Responsibility in Policy #EOC-003 II.
e) Medical Center Management Team did not adhere to their Responsibility in Policy #EOC-003 II.
f) Section III-Procedure of the Policy #EOC-003 was not followed by the facility staff.

All smoking policy requirements shall be adhered to as required. Failure to do so has the potential to promote harm to residents of the facility.

Based on observation of the physical environment and interviews with the facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not ensuring that the means of egress in the facility serving as exit access are clear and are unobstructed as required.

The findings include:

1) During the complaint survey on December 17, 2013 at approximately 1110 hours it was observed and confirmed through interview with the Safety Director and Nursing Staff that on the 12th floor of the North Building in the East Wing (Geriatric Psych) there were 3 (three) beds stored in the corridor obstructing this means of egress. These beds are used for transport of patients to and from other areas for various treatments, etc. It is understood that staff in this area perform the transport of these patients unlike other areas of the hospital due to the special needs of the patients, therefore the beds must remain in proximity to the use area, however means of egress corridors shall not be used for the storage of these beds..

2) See K-075 also.

The reduced width of the means of egress components in the facility and the storage of items within means of egress components has the potential to promote harm to occupants of the facility in the event of a fire or other emergency.

Based on observation of the physical environment and interviews with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining soiled linen and trash receptacles in approved hazardous areas as required.

1) During the complaint survey on December 17, 2013 at approximately 1015 hours it was observed and confirmed through interview with the Safety Director that there were two (2) wheeled carts each holding two (2) 44 gallon capacity "Brute" trash receptacles containing combustible trash stored in the N13E08 anteroom. This room is not protected as a hazardous area as there is no separation to the egress corridor. All trash and soiled lined receptacles in the facility that contain trash and linens shall comply with 19.7.5.5.

2) During the complaint survey on December 17, 2013 at approximately 1045 hours it was observed and confirmed through interview with the Safety Director that there were two (2) wheeled trash receptacles exceeding 32 gallon capacity (approximately 18 cubic feet each) containing combustible trash stored in the N10W corridor.

All soiled linen or trash collection receptacles over 32 gallons capacity must be maintained in accordance with all requirements of NFPA 101. This has the potential to promote harm to occupants of the facility in the event of a fire in this area.

Based on observation of the physical environment and interview with the facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining medical gas storage in accordance with NFPA 99 requirements.

The findings include:

1) During the complaint survey on December 17, 2013 at approximately 1105 hours it was observed and confirmed through interview with the Safety Director that the N12E31 Examination Room, used for Oxygen Storage, door to the corridor lacked the required self closing device.

This room was observed to contain 8 "E" cylinders and 1 "H" cylinder of oxygen at the time of the survey (total capacity 450 cubic feet).

Failure to protect medical gas storage areas as required has the potential to promote harm to occupants of the building in the event of a fire.

Based on observation of the physical environment and interview with facility staff it was determined that the facility staff failed to insure that there are readily visible "EXIT" signs indicating access to exits in all areas, thereby creating an unsafe condition.

The findings include:

1) During the complaint survey on December 17, 2013 at approximately 1145 hours it was observed and confirmed through interview with the Safety Director that in the North Hospital Building ground floor "Dental Clinic" a required second means of egress is not marked with "EXIT" signs as required.

The failure to designate and properly mark EXIT access and direction thereto has the potential to promote harm to occupants of the building in the event of a fire or other emergency.

Based on observation of the physical environment, interview with facility staff, and review of the facility's records it was determined that the facility staff failed to provide a safe and hazard free environment by not enforcing the facility smoking policy and/or maintaining a hazard free smoking area.

The findings include:

1) During the complaint survey on December 17, 2013 a copy of the facility smoking policy was requested and obtained for review by this surveyor (Policy #EOC-003, rev. 12/12). Information received from other survey team members related to the patient involved in the incident which prompted this complaint survey and was also reviewed. After reviewing all information related to the smoking policy of University of Maryland Medical Center as submitted per this request and information from survey team members, it was determined that:
a) Nursing staff did not adhere to their Responsibility in Policy #EOC-003 II.
b) Physician did not adhere to his/her Responsibility in Policy #EOC-003 II.
c) UMMC Employees did not adhere to their Responsibility in Policy #EOC-003 II.
d) Security Department personnel did not adhere to their Responsibility in Policy #EOC-003 II.
e) Medical Center Management Team did not adhere to their Responsibility in Policy #EOC-003 II.
f) Section III-Procedure of the Policy #EOC-003 was not followed by the facility staff.

All smoking policy requirements shall be adhered to as required. Failure to do so has the potential to promote harm to residents of the facility.

Based on observation of the physical environment and interviews with the facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not ensuring that the means of egress in the facility serving as exit access are clear and are unobstructed as required.

The findings include:

1) During the complaint survey on December 17, 2013 at approximately 1110 hours it was observed and confirmed through interview with the Safety Director and Nursing Staff that on the 12th floor of the North Building in the East Wing (Geriatric Psych) there were 3 (three) beds stored in the corridor obstructing this means of egress. These beds are used for transport of patients to and from other areas for various treatments, etc. It is understood that staff in this area perform the transport of these patients unlike other areas of the hospital due to the special needs of the patients, therefore the beds must remain in proximity to the use area, however means of egress corridors shall not be used for the storage of these beds..

2) See K-075 also.

The reduced width of the means of egress components in the facility and the storage of items within means of egress components has the potential to promote harm to occupants of the facility in the event of a fire or other emergency.

Based on observation of the physical environment and interviews with facility staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining soiled linen and trash receptacles in approved hazardous areas as required.

1) During the complaint survey on December 17, 2013 at approximately 1015 hours it was observed and confirmed through interview with the Safety Director that there were two (2) wheeled carts each holding two (2) 44 gallon capacity "Brute" trash receptacles containing combustible trash stored in the N13E08 anteroom. This room is not protected as a hazardous area as there is no separation to the egress corridor. All trash and soiled lined receptacles in the facility that contain trash and linens shall comply with 19.7.5.5.

2) During the complaint survey on December 17, 2013 at approximately 1045 hours it was observed and confirmed through interview with the Safety Director that there were two (2) wheeled trash receptacles exceeding 32 gallon capacity (approximately 18 cubic feet each) containing combustible trash stored in the N10W corridor.

All soiled linen or trash collection receptacles over 32 gallons capacity must be maintained in accordance with all requirements of NFPA 101. This has the potential to promote harm to occupants of the facility in the event of a fire in this area.

Based on observation of the physical environment and interview with the facility staff it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining medical gas storage in accordance with NFPA 99 requirements.

The findings include:

1) During the complaint survey on December 17, 2013 at approximately 1105 hours it was observed and confirmed through interview with the Safety Director that the N12E31 Examination Room, used for Oxygen Storage, door to the corridor lacked the required self closing device.

This room was observed to contain 8 "E" cylinders and 1 "H" cylinder of oxygen at the time of the survey (total capacity 450 cubic feet).

Failure to protect medical gas storage areas as required has the potential to promote harm to occupants of the building in the event of a fire.