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Based on observation and interview with staff, it was determined that the facility failed to provide a safe means of egress out of the emergency exit doors. Failure to provide a clear and unimpeded means of egress could cause harm to the patients and staff in a fire emergency.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10.1 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency." Section 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto egress therefrom, or visibility thereof."

During a facility tour conducted on July13-15,2021, observed the emergency exit doors on both sides, located in the IT building (White Whale) was impeded by storage of IT cords and equipment, and ladders.

Employee #9 acknowledged during the exit conference on July 15, 2021, that the emergency exit doors located in the "White Whale IT building" were impeded.

Based on record review and observation it was determined the facilities Alcohol Based Hand Rub Dispensers were not tested in accordance with the manufactures care and use instructions each time a refill is installed. ABHR dispensers not tested in accordance with the manufactures care and use instructions each time a refill is installed could cause the dispenser not to operate in an effective manner if needed. Failure to test dispensers as recommended by the manufacture could result in leakage and result in a fire with possible injury or death.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.6 ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met:
* Corridor is at least 6 feet wide
* Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols
* Dispensers shall have a minimum of 4-foot horizontal spacing
* Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room
* Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30
* Dispensers are not installed within 1 inch of an ignition source
* Dispensers over carpeted floors are in sprinklered smoke compartments
* ABHR does not exceed 95 percent alcohol
* Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11)
* ABHR is protected against inappropriate access

Operation of the dispenser(s) shall comply with the following criteria: (F) The dispenser shall be tested in accordance with the manufactures care and use instructions each time a refill is installed.

CDC states:
The dispenser shall:
Not release its contents except when the dispenser is activated, either manually or automatically by touch-free activation.
Not dispense more solution than the amount required for hand hygiene consistent with label instructions.
Be designed, constructed and operated in a manner that ensures accidental or malicious activation is minimized.
Be tested in accordance with the manufacturer ' s care and use instructions each time a new refill is installed.
Any activation of the dispenser shall only occur when an object is placed within 4 inches (100mm) of the sensor.
An object placed within the activation zone and left in place shall not cause more than one activation.

Findings include:

During a facility tour conducted on July 13-15, 2021, it was determined the facility did not have documented evidence that the facilities Alcohol Based Hand Rub Dispensers were tested in accordance with the manufactures care and use instructions each time a refill is installed. There was no policy or any other written documentation that the refills were tested in accordance with the manufactures care and use instructions shown to the surveyor while on site. In addition over 20 dispensers were discovered with expired product in the dispenser.

Employee #9 acknowledged during the exit conference that the ABHR dispensers were not tested as required and a large amount were expired.

Based on observation it was determined the the facility failed to prevent fire extinguisher from being blocked and readily accessible on the Helo Pad of the facility. Failing to have clear access to a fire extinguisher during an emergency could result in harm to the patients and/or staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.12 "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1" Section 9.7.4.1 "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for portable Fire Extinguishers." NFPA 10, Chapter 7, Section 7.2.2 Periodic inspections or electronic monitoring of fire extinguishers shall include a check of at least the following items: No obstruction to access or visibility.

Findings include:

During a facility tour conducted on July 13,2021 three (3) portable fire extinguishers located in the Helocopter pad area of the facility was being blocked by a portable O2 cart and other storage bins obstructing the fire extinguisher and three (3) additional extinguishers were in a location that required the person to cross over a rock area inhibing access.

Employee #9 acknowledged during the exit conference on July 15, 2021 that the extinguishers were obstructed on the helo pad.

Based on observation it was determined the facility failed to fill penetrations in two of the smoke barriers in main hospital. Failing to fill the penetrations, will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients in time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall , floor or /ceiling assembly constructed as a smoke barrier , or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

Observations during a facility tour conducted on July 13-15, 2021, revealed unsealed penetrations, (holes in the smoke barriers) located above smoke control doors SC06 and SC20 and above 1338 there was also holes in ceiling tiles above 1080. There was also a hole in the fire barrier in the electrical room of the OSC.

Employee #9 acknowledged during the exit conference conducted on July 13-15, 2021 the holes in the smoke barriers and ceiling tiles.

Based on observation and staff interview it was determined, the facility failed to ensure their were protected covering over exposed wires. Failure to have the appropriate protection around exposed wires could cause harm to staff and patients.

NFPA 101, 2012 Edition Chapter 19. "19.5.1 Utilities. 19.5.1.1 Utilities shall comply with the provisions of Section 9.1" " 9.1 Utilities. 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, 2011 Edition Chapter 1 General "110.27(A) Live Parts Guarded Against Accidental Contact. Except as elsewhere required or permitted by this Code, live parts of electrical equipment operating at 50 volts or more shall be guarded against accidental contact by approved enclosures or by any of the following means: (1) By location in a room, vault, or similar enclosure that is accessible only to qualified persons. (2) By suitable permanent, substantial partitions or screens arranged so that only qualified persons have access to the space within reach of the live parts. Any openings in such partitions or screens shall be sized and located so that persons are not likely to come into accidental contact with the live parts or to bring conducting objects into contact with them. (3) By location on a suitable balcony, gallery, or platform elevated and arranged so as to exclude unqualified persons. (4) By elevation of 2.5 m (8 ft) or more above the floor or other working surface."

Findings include:

Observations while on tour July 13-15, 2021 reveled, exposed wires coming from four (4) open junction boxes in the tower mechcanical room and one over smoke control door SC20, the J Boxes were missing the cover.

Employee #9 acknowledged during the exit conference on July 15, 2021, that there were exposed wires that were not covered with the appropriate J box covers.

Based on Observation it was determined the facility allowed the use of a multiple extension cords and did not use the wall outlet receptacles for appliances. Failure to properly use power cords and outlets could lead to electrical overload or fire which could cause harm to the patients and staff.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

Observations while on tour July 13-15, 2021 revealed the following locations with extension cords as permanent equipment
1. Extension cord used to power the refridgerator in the Dr bed room on the 4 floor
2. Extension cord used in the delivery room OR (Covid side)
3. Extension cord used in the pharmacy
4. Extension cord used in the old EROU nurses station
5. Daisy chained power strip in the charge nurses office on the third floor


During the exit conference conducted on July 15, 2021, Employee #9 confirmed the improper use of power strips and extension cords.

Based on Observation the facility failed to secure two medical gas O2 cylinders that were not in a stand /cart or secured to the wall. Failing to secure compressed medical gas cylinders could cause harm to the patients and staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.2.3 (11) Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart."

Findings include:

Observations while on tour July 13-15, 2021 revealed two (2) unsecured oxygen cylinders one was located in the ED nurses station and the other was located in room 1620.

During the exit conference conducted on July 15, 2021 Employees #9 acknowledged the unsecured oxygen cylinders found in ED and Room 1620.

Based on interview and program review it was determined the facility failed to provide programs for continuing education and periodic review of safety guidelines and usage requirements for medical gases and oxygen cylinders. Failing to provide programs and periodic review of safety guidelines of oxygen cylinders or liquid oxygen could cause harm to the patients and staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.5.2.1" Gas Equipment - Qualifications and Training of Personnel Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment.

Findings include:

During review of the facilities documentation conducted on July 13-15, 2021 revealed that the facility did not have a continuing education program for oxygen risk. Additionally staff interview also confirmed this.The facility does provide initial training to staff.

Employees #9 acknowledged during the exit conference that the none of the facilities surveyed had a continuing oxygen risk training program.The facility does provide initial training to staff.