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Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On March 24, 2014, the surveyor accompanied by the Director of Facilities & Improvements; Supervisor of Fire & Automation; Supervisor of Building Maintenance; Safety Officer; Director of Security & Safety; Director of Pt. Care Services; and VP of Facilities, observed the following corridor doors would not tightly close when tested.

1. Case Management office unit 420, door with a door closing device wedged open.
2. Women's triage, room 175, door has holes.
3. Labor and delivery, GYN surgery lounge, door wedged open.

During the exit conference on March 26, 2014, the above findings were again acknowledged by the VP of Facilities; Director of Facilities; Director of Security; Nursing; Director of Quality; CNO; Director of In Pt. Adult M/S Med/Surg; COO; Director of ED; and Director of Care.

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation the facility failed to maintain the self closing/automatic-closing doors in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Sections, 19.3.7.6 "Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. ( See Chapter 19 for additional requirements) Chapter 8, Section 8.3.4."Doors" Section 8.3.4.3, "Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. Section 7.2.1.8.1 (1) "Upon release of the hold-open mechanism, the door becomes self-closing."

On March 24, 2014, the surveyor accompanied by the Director of Facilities & Improvements; Supervisor of Fire & Automation; Supervisor of Building Maintenance; Safety Officer; Director of Security & Safety; Director of Pt. Care Services; and VP of Facilities, observed the third floor N.W. PACU smoke barrier doors. The double smoke barrier doors were tested by activation of the Fire Alarm, the doors failed to positively latch as designed by the manufacture; and the astragal was removed from the corridor smoke/fire doors in the 600 area; 750 E; and 850 W.

During the exit conference on March 26, 2014, the above findings were again acknowledged by the VP of Facilities; Director of Facilities; Director of Security; Nursing; Director of Quality; CNO; Director of In Pt. Adult M/S Med/Surg; COO; Director of ED; and Director of Care.

Failure to properly adjust or repair the smoke doors could cause harm to residents.
Non closing smoke doors could allow smoke to enter smoke zones not directly effected by the fire, which could cause harm to the patients.

Based on observation the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings include:

On March 24, 2014, the surveyor accompanied by the Director of Facilities & Improvements; Supervisor of Fire & Automation; Supervisor of Building Maintenance; Safety Officer; Director of Security & Safety; Director of Pt. Care Services; and VP of Facilities, observed the following hazardous area doors:

1. Forth floor, S.W. trash room door tested three of three times will not positively latch.
2. Third floor, trash room by Sage Nurses station, tested three of three times will not positively latch.
3. Ortho. Surgery #3, Janitors closet, held open with an impediment, will not positively latch.
4. Second floor, soiled utility, tested three of three times, will not positively latch.
5. East Exit by the 460's, storage room with combustibles, no door closing device.
6. Peppers storage room, flammables and combustibles, no door closing device.
7. Cath Lab/Post Procedure door, closing device removed and latching mechanism taped not to latch
8. Cath Lab supplies room, door closing device removed, room greater than 50 sq. ft.
9. ER trash room, door will not positively latch.
10 DES/Access office, storage room with combustibles, no closing device and will not close and positively latch.
11. Janitors closet by the Chapel, latch taped, door will not close and positively latch.
12. Kitchen door from short order grill will not close tight.
13. Storage(catering)flammables stored in the room, no door closing device or flammable cabinet.
14. Janitor closet, greater than 50 sq. ft; door tied open with a red nylon strap, will not close and positively latch

During the exit conference on March 26, 2014, the above findings were again acknowledged by the VP of Facilities; Director of Facilities; Director of Security; Nursing; Director of Quality; CNO; Director of In Pt. Adult M/S Med/Surg; COO; Director of ED; and Director of Care.

Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

Based on observation the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 18.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

Findings include:

On March 24, 2014, the surveyor accompanied by the Director of Facilities & Improvements; Supervisor of Fire & Automation; Supervisor of Building Maintenance; Safety Officer; Director of Security & Safety; Director of Pt. Care Services; and VP of Facilities, observed storage of a full size refrigerator and a table with a Pixis computer, within the exit corridor. The storage was blocking the exit access located in the Cath Lab Post procedure unit reducing the exit access when measured from six feet to three feet six inches.

During the exit conference on March 26, 2014, the above findings were again acknowledged by the VP of Facilities; Director of Facilities; Director of Security; Nursing; Director of Quality; CNO; Director of In Pt. Adult M/S Med/Surg; COO; Director of ED; and Director of Care.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

Based on interview, staff members did not know the life safety procedures and devices.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings Include:

On March 24, 2014, the surveyor accompanied by the Director of Facilities & Improvements; Supervisor of Fire & Automation; Supervisor of Building Maintenance; Safety Officer; Director of Security & Safety; Director of Pt. Care Services; and VP of Facilities, interviewed ten employees out of approximately one hundred employees. One employee from "Cell Saver" who has worked approximately one hundred days out of the last year, stated the facilities does not have fire drill training. The nine DES/ACCESS office employees stated there office does not have an audible fire alarm.

During the exit conference on March 26, 2014, the above findings were again acknowledged by the VP of Facilities; Director of Facilities; Director of Security; Nursing; Director of Quality; CNO; Director of In Pt. Adult M/S Med/Surg; COO; Director of ED; and Director of Care.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on observation the facility failed to maintain the sprinkler heads from obstructions; and failed to maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." ." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, Chapter 5, Section 5-8.5.1.1, "Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-8.5.2 and 5-8.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard." Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection systems. NFPA 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation..." NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings include:

On March 24, 2014, the surveyor accompanied by the Director of Facilities & Improvements; Supervisor of Fire & Automation; Supervisor of Building Maintenance; Safety Officer; Director of Security & Safety; Director of Pt. Care Services; and VP of Facilities, observed the following sprinkler heads located in the following area:

1. Women's triage, room 175, sprinkler had lint.
2. Labor and delivery, three sprinklers had paint, one had lint.
3. Kitchen, walk in cooler #9, two of three sprinklers corroded.
4. Kitchen, walk in cooler #8, one of two sprinklers corroded.
5. Kitchen coolers #6 & 7, one of two sprinklers each obstructed by the light.

During the exit conference on March 26, 2014, the above findings were again acknowledged by the VP of Facilities; Director of Facilities; Director of Security; Nursing; Director of Quality; CNO; Director of In Pt. Adult M/S Med/Surg; COO; Director of ED; and Director of Care.

Installing obstructions next to the sprinkler head may prevent it from providing adequate coverage of the hazard. And failing to maintain sprinkler heads and keep the fusible link clean could allow a fire to burn longer before the sprinkler head will activate. Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, could allow heat and smoke to effect other areas of the building. This could cause harm to the patients.

Based on Observation the facility failed to separate empty and full medical gas cylinders; provide empty/full signs for medical gas cylinders; and keep the oxygen/medical bottles secured.

NFPA 101 Life Safety Code, 2000, 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, Chapter 4, Section 4-3.5.2.2 (a) (2) "If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

NFPA 101 Life Safety Code, 2000, 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 Chapter 8, Section 8-3.1.11.2 (3) (h) Cylinder or container restraint shall meet 4-3.5.2.1(b) (27)." Section 4-3.5.2.1(b)(27) "Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart."


Findings Include:

On March 24, 2014, the surveyor accompanied by the Director of Facilities & Improvements; Supervisor of Fire & Automation; Supervisor of Building Maintenance; Safety Officer; Director of Security & Safety; Director of Pt. Care Services; and VP of Facilities, observed the following medical gasses:

1. Third floor recovery, two of six E O2 bottles full, four empty, not marked full/empty.
2. Second floor PACU, bay #26, three empty and three full, not marked full/empty
3. Unit 480/490, two helium bottles stored unsecured laying on a shelf
4. Basement, surgery equipment area, unsecured medical gases on the floor
5. Oxygen storage room, NICU, one O2 H tank; ten E O2 and four Air E type bottles. No full/empty signs, double doors vented to corridor and a gap between the doors greater than 1/8th inch.
6. Women's unit by room 138, three EO2 bottles, one unsecured by combustibles

During the exit conference on March 26, 2014, the above findings were again acknowledged by the VP of Facilities; Director of Facilities; Director of Security; Nursing; Director of Quality; CNO; Director of In Pt. Adult M/S Med/Surg; COO; Director of ED; and Director of Care.

In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

Based on observation the facility failed to store flammable liquids in an approved flammable/combustible liquid cabinet.

NFPA 101 Life Safety Code, 2000 Chapter 19, Section 19.3.2 "Protection from Hazards,"
19.3.2.2 "Laboratories," and Table 19.3.2.1 "Physical plant maintenance shops." and "Storage Rooms"
or Chapter 19, Section, 19.3.2.1 "Hazardous Areas" "(4) Repair shops," "(7) Storage rooms,"
and (8) " Laboratories." 19.3.2.2* Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered as a severe hazard shall be protected in accordance with NFPA 99. 10-1.2.1* NFPA 45, standard for Fire Protection for Laboratories Using Chemicals.

Findings include:

On March 24, 2014, the surveyor accompanied by the Director of Facilities & Improvements; Supervisor of Fire & Automation; Supervisor of Building Maintenance; Safety Officer; Director of Security & Safety; Director of Pt. Care Services; and VP of Facilities, observed;

1. The storage of two gallons of Xylene a flammable liquid, regulated by OSHA in the Laboratory openly on a table.
2. Tissue storage room, a door with no closing device.
3. Storage room with combustibles, no door closing device.
4. Flammable waste collection site container holds up to thirty gallons, no provision to control a spill up to five gallons and the container is not closed and secure.

During the exit conference on March 26, 2014, the above findings were again acknowledged by the VP of Facilities; Director of Facilities; Director of Security; Nursing; Director of Quality; CNO; Director of In Pt. Adult M/S Med/Surg; COO; Director of ED; and Director of Care.

Failing to store flammable and combustible liquids properly may create a spill hazard, and will contribute to a fire, which will cause harm to patients and staff.

Based on observation the facility failed to allow access to the electrical equipment/panels; failed to provide battery operated emergency lighting in the operating rooms, anesthetizing locations; and failed to provide a guard on the light bulb located in the supply closet.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions.

( NO STORAGE ALLOWED IN THE WORKING SPACE)

Section 9.1. Section 9.1.2 "Electric wiring and equipment shall be in accordance with NFPA 70 National Electrical Code... Article 517 Health Care Facilities, Section 517-63 Grounded Power systems in Anesthetizing Locations. 517-63(a), 'Battery-Powered Emergency Lighting Units." "One or more battery-powered emergency lighting units shall be provided in accordance with Section 700-12(e)." NFPA 99, Health Care Facilities, Chapter 3, Section 3-3.2.1.2, (5) Wiring in Anesthetizing Locations. (e) Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, Section 700-12 (e).
"Electrical wiring and equipment installed shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, Article 110, Section 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage. 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, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) 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:

On March 24, 2014, the surveyor accompanied by the Director of Facilities & Improvements; Supervisor of Fire & Automation; Supervisor of Building Maintenance; Safety Officer; Director of Security & Safety; Director of Pt. Care Services; and VP of Facilities, observed the following electrical issues:

1. DR2 120 V Electrical panel approximately two by three foot opening, exposed energized electrical.
2. Support services, micro wave and refrigerator plugged into a power strip.
3. Main OR 1, South ER, emergency battery back up light failed.
4. Peppers storage room, no light cover.
5. Peppers, electric panels, SB-P and SB-PA blocked.
6. Cath Lab, break room has a refrigerator plugged into an extension cord.

During the exit conference on March 26, 2014, the above findings were again acknowledged by the VP of Facilities; Director of Facilities; Director of Security; Nursing; Director of Quality; CNO; Director of In Pt. Adult M/S Med/Surg; COO; Director of ED; and Director of Care.

Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation; failing to provide battery-powered emergency lighting in the operating rooms will harm patients during a power outage; failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients; and the use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

Based on document review the facility failed to test the fire fighter service, monthly, on all elevators.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.3, "Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4. Section 9.4.6 "Elevator Testing." "Elevators shall be subject to routine and periodic inspections and tests as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators. All elevators equipped with fire fighter service in accordance with 9.4.4 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME/ANSI A17.1, Safety Code for Elevators and Escalators."

Findings include:

On March 24, 2014, the surveyor accompanied by the Director of Facilities & Improvements; Supervisor of Fire & Automation; Supervisor of Building Maintenance; Safety Officer; Director of Security & Safety; Director of Pt. Care Services; and VP of Facilities reviewed the monthly elevator fire fighter service test documentation. The facility did not test the fire fighter service on a monthly schedule. The facilities test and documentation was every other month.

During the exit conference on March 26, 2014, the above findings were again acknowledged by the VP of Facilities; Director of Facilities; Director of Security; Nursing; Director of Quality; CNO; Director of In Pt. Adult M/S Med/Surg; COO; Director of ED; and Director of Care.

Fire fighter service is critical during an emergency and failing to test the elevators may cause harm to patients, staff and visitors.

Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On March 24, 2014, the surveyor accompanied by the Director of Facilities & Improvements; Supervisor of Fire & Automation; Supervisor of Building Maintenance; Safety Officer; Director of Security & Safety; Director of Pt. Care Services; and VP of Facilities, observed the following corridor doors would not tightly close when tested.

1. Case Management office unit 420, door with a door closing device wedged open.
2. Women's triage, room 175, door has holes.
3. Labor and delivery, GYN surgery lounge, door wedged open.

During the exit conference on March 26, 2014, the above findings were again acknowledged by the VP of Facilities; Director of Facilities; Director of Security; Nursing; Director of Quality; CNO; Director of In Pt. Adult M/S Med/Surg; COO; Director of ED; and Director of Care.

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation the facility failed to maintain the self closing/automatic-closing doors in the smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Sections, 19.3.7.6 "Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. ( See Chapter 19 for additional requirements) Chapter 8, Section 8.3.4."Doors" Section 8.3.4.3, "Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. Section 7.2.1.8.1 (1) "Upon release of the hold-open mechanism, the door becomes self-closing."

On March 24, 2014, the surveyor accompanied by the Director of Facilities & Improvements; Supervisor of Fire & Automation; Supervisor of Building Maintenance; Safety Officer; Director of Security & Safety; Director of Pt. Care Services; and VP of Facilities, observed the third floor N.W. PACU smoke barrier doors. The double smoke barrier doors were tested by activation of the Fire Alarm, the doors failed to positively latch as designed by the manufacture; and the astragal was removed from the corridor smoke/fire doors in the 600 area; 750 E; and 850 W.

During the exit conference on March 26, 2014, the above findings were again acknowledged by the VP of Facilities; Director of Facilities; Director of Security; Nursing; Director of Quality; CNO; Director of In Pt. Adult M/S Med/Surg; COO; Director of ED; and Director of Care.

Failure to properly adjust or repair the smoke doors could cause harm to residents.
Non closing smoke doors could allow smoke to enter smoke zones not directly effected by the fire, which could cause harm to the patients.

Based on observation the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings include:

On March 24, 2014, the surveyor accompanied by the Director of Facilities & Improvements; Supervisor of Fire & Automation; Supervisor of Building Maintenance; Safety Officer; Director of Security & Safety; Director of Pt. Care Services; and VP of Facilities, observed the following hazardous area doors:

1. Forth floor, S.W. trash room door tested three of three times will not positively latch.
2. Third floor, trash room by Sage Nurses station, tested three of three times will not positively latch.
3. Ortho. Surgery #3, Janitors closet, held open with an impediment, will not positively latch.
4. Second floor, soiled utility, tested three of three times, will not positively latch.
5. East Exit by the 460's, storage room with combustibles, no door closing device.
6. Peppers storage room, flammables and combustibles, no door closing device.
7. Cath Lab/Post Procedure door, closing device removed and latching mechanism taped not to latch
8. Cath Lab supplies room, door closing device removed, room greater than 50 sq. ft.
9. ER trash room, door will not positively latch.
10 DES/Access office, storage room with combustibles, no closing device and will not close and positively latch.
11. Janitors closet by the Chapel, latch taped, door will not close and positively latch.
12. Kitchen door from short order grill will not close tight.
13. Storage(catering)flammables stored in the room, no door closing device or flammable cabinet.
14. Janitor closet, greater than 50 sq. ft; door tied open with a red nylon strap, will not close and positively latch

During the exit conference on March 26, 2014, the above findings were again acknowledged by the VP of Facilities; Director of Facilities; Director of Security; Nursing; Director of Quality; CNO; Director of In Pt. Adult M/S Med/Surg; COO; Director of ED; and Director of Care.

Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

Based on observation the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 18.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

Findings include:

On March 24, 2014, the surveyor accompanied by the Director of Facilities & Improvements; Supervisor of Fire & Automation; Supervisor of Building Maintenance; Safety Officer; Director of Security & Safety; Director of Pt. Care Services; and VP of Facilities, observed storage of a full size refrigerator and a table with a Pixis computer, within the exit corridor. The storage was blocking the exit access located in the Cath Lab Post procedure unit reducing the exit access when measured from six feet to three feet six inches.

During the exit conference on March 26, 2014, the above findings were again acknowledged by the VP of Facilities; Director of Facilities; Director of Security; Nursing; Director of Quality; CNO; Director of In Pt. Adult M/S Med/Surg; COO; Director of ED; and Director of Care.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

Based on interview, staff members did not know the life safety procedures and devices.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings Include:

On March 24, 2014, the surveyor accompanied by the Director of Facilities & Improvements; Supervisor of Fire & Automation; Supervisor of Building Maintenance; Safety Officer; Director of Security & Safety; Director of Pt. Care Services; and VP of Facilities, interviewed ten employees out of approximately one hundred employees. One employee from "Cell Saver" who has worked approximately one hundred days out of the last year, stated the facilities does not have fire drill training. The nine DES/ACCESS office employees stated there office does not have an audible fire alarm.

During the exit conference on March 26, 2014, the above findings were again acknowledged by the VP of Facilities; Director of Facilities; Director of Security; Nursing; Director of Quality; CNO; Director of In Pt. Adult M/S Med/Surg; COO; Director of ED; and Director of Care.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on observation the facility failed to maintain the sprinkler heads from obstructions; and failed to maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.1, "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." ." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, Chapter 5, Section 5-8.5.1.1, "Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-8.5.2 and 5-8.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard." Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection systems. NFPA 25, Section 2-2.1.1 "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material , paint, and physical damage and shall be installed in the proper orientation..." NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, Chapter 3, Section 3-2.7.2, "Escutcheon Plates used with a recessed or flushed sprinkler shall be part of a listed sprinkler assembly."

Findings include:

On March 24, 2014, the surveyor accompanied by the Director of Facilities & Improvements; Supervisor of Fire & Automation; Supervisor of Building Maintenance; Safety Officer; Director of Security & Safety; Director of Pt. Care Services; and VP of Facilities, observed the following sprinkler heads located in the following area:

1. Women's triage, room 175, sprinkler had lint.
2. Labor and delivery, three sprinklers had paint, one had lint.
3. Kitchen, walk in cooler #9, two of three sprinklers corroded.
4. Kitchen, walk in cooler #8, one of two sprinklers corroded.
5. Kitchen coolers #6 & 7, one of two sprinklers each obstructed by the light.

During the exit conference on March 26, 2014, the above findings were again acknowledged by the VP of Facilities; Director of Facilities; Director of Security; Nursing; Director of Quality; CNO; Director of In Pt. Adult M/S Med/Surg; COO; Director of ED; and Director of Care.

Installing obstructions next to the sprinkler head may prevent it from providing adequate coverage of the hazard. And failing to maintain sprinkler heads and keep the fusible link clean could allow a fire to burn longer before the sprinkler head will activate. Failing to maintain sprinkler heads, missing escutcheon plates, which are part of the UL Listing of the sprinkler assembly, could allow heat and smoke to effect other areas of the building. This could cause harm to the patients.

Based on Observation the facility failed to separate empty and full medical gas cylinders; provide empty/full signs for medical gas cylinders; and keep the oxygen/medical bottles secured.

NFPA 101 Life Safety Code, 2000, 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, Chapter 4, Section 4-3.5.2.2 (a) (2) "If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

NFPA 101 Life Safety Code, 2000, 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 Chapter 8, Section 8-3.1.11.2 (3) (h) Cylinder or container restraint shall meet 4-3.5.2.1(b) (27)." Section 4-3.5.2.1(b)(27) "Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart."


Findings Include:

On March 24, 2014, the surveyor accompanied by the Director of Facilities & Improvements; Supervisor of Fire & Automation; Supervisor of Building Maintenance; Safety Officer; Director of Security & Safety; Director of Pt. Care Services; and VP of Facilities, observed the following medical gasses:

1. Third floor recovery, two of six E O2 bottles full, four empty, not marked full/empty.
2. Second floor PACU, bay #26, three empty and three full, not marked full/empty
3. Unit 480/490, two helium bottles stored unsecured laying on a shelf
4. Basement, surgery equipment area, unsecured medical gases on the floor
5. Oxygen storage room, NICU, one O2 H tank; ten E O2 and four Air E type bottles. No full/empty signs, double doors vented to corridor and a gap between the doors greater than 1/8th inch.
6. Women's unit by room 138, three EO2 bottles, one unsecured by combustibles

During the exit conference on March 26, 2014, the above findings were again acknowledged by the VP of Facilities; Director of Facilities; Director of Security; Nursing; Director of Quality; CNO; Director of In Pt. Adult M/S Med/Surg; COO; Director of ED; and Director of Care.

In an emergency, patients could be harmed if an empty medical gas cylinder was mistakenly taken from the storage area.

Based on observation the facility failed to store flammable liquids in an approved flammable/combustible liquid cabinet.

NFPA 101 Life Safety Code, 2000 Chapter 19, Section 19.3.2 "Protection from Hazards,"
19.3.2.2 "Laboratories," and Table 19.3.2.1 "Physical plant maintenance shops." and "Storage Rooms"
or Chapter 19, Section, 19.3.2.1 "Hazardous Areas" "(4) Repair shops," "(7) Storage rooms,"
and (8) " Laboratories." 19.3.2.2* Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered as a severe hazard shall be protected in accordance with NFPA 99. 10-1.2.1* NFPA 45, standard for Fire Protection for Laboratories Using Chemicals.

Findings include:

On March 24, 2014, the surveyor accompanied by the Director of Facilities & Improvements; Supervisor of Fire & Automation; Supervisor of Building Maintenance; Safety Officer; Director of Security & Safety; Director of Pt. Care Services; and VP of Facilities, observed;

1. The storage of two gallons of Xylene a flammable liquid, regulated by OSHA in the Laboratory openly on a table.
2. Tissue storage room, a door with no closing device.
3. Storage room with combustibles, no door closing device.
4. Flammable waste collection site container holds up to thirty gallons, no provision to control a spill up to five gallons and the container is not closed and secure.

During the exit conference on March 26, 2014, the above findings were again acknowledged by the VP of Facilities; Director of Facilities; Director of Security; Nursing; Director of Quality; CNO; Director of In Pt. Adult M/S Med/Surg; COO; Director of ED; and Director of Care.

Failing to store flammable and combustible liquids properly may create a spill hazard, and will contribute to a fire, which will cause harm to patients and staff.

Based on observation the facility failed to allow access to the electrical equipment/panels; failed to provide battery operated emergency lighting in the operating rooms, anesthetizing locations; and failed to provide a guard on the light bulb located in the supply closet.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1., Section 9.1.2 "Electrical wiring and equipment shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, ARTICLE 110, SECTION 110-26 Spaces About Electrical Equipment. "Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons." Table 110-26(a) Working Space Minimum of three (3) feet in all directions.

( NO STORAGE ALLOWED IN THE WORKING SPACE)

Section 9.1. Section 9.1.2 "Electric wiring and equipment shall be in accordance with NFPA 70 National Electrical Code... Article 517 Health Care Facilities, Section 517-63 Grounded Power systems in Anesthetizing Locations. 517-63(a), 'Battery-Powered Emergency Lighting Units." "One or more battery-powered emergency lighting units shall be provided in accordance with Section 700-12(e)." NFPA 99, Health Care Facilities, Chapter 3, Section 3-3.2.1.2, (5) Wiring in Anesthetizing Locations. (e) Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, Section 700-12 (e).
"Electrical wiring and equipment installed shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, Article 110, Section 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage. 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, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) 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:

On March 24, 2014, the surveyor accompanied by the Director of Facilities & Improvements; Supervisor of Fire & Automation; Supervisor of Building Maintenance; Safety Officer; Director of Security & Safety; Director of Pt. Care Services; and VP of Facilities, observed the following electrical issues:

1. DR2 120 V Electrical panel approximately two by three foot opening, exposed energized electrical.
2. Support services, micro wave and refrigerator plugged into a power strip.
3. Main OR 1, South ER, emergency battery back up light failed.
4. Peppers storage room, no light cover.
5. Peppers, electric panels, SB-P and SB-PA blocked.
6. Cath Lab, break room has a refrigerator plugged into an extension cord.

During the exit conference on March 26, 2014, the above findings were again acknowledged by the VP of Facilities; Director of Facilities; Director of Security; Nursing; Director of Quality; CNO; Director of In Pt. Adult M/S Med/Surg; COO; Director of ED; and Director of Care.

Blocking of access to electrical panels or equipment may delay personnel from controlling an emergency situation; failing to provide battery-powered emergency lighting in the operating rooms will harm patients during a power outage; failure to keep light guards on the light could cause accidental damage or possibly a fire, which could cause harm to the patients; and the use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

Based on document review the facility failed to test the fire fighter service, monthly, on all elevators.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.3, "Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4. Section 9.4.6 "Elevator Testing." "Elevators shall be subject to routine and periodic inspections and tests as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators. All elevators equipped with fire fighter service in accordance with 9.4.4 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME/ANSI A17.1, Safety Code for Elevators and Escalators."

Findings include:

On March 24, 2014, the surveyor accompanied by the Director of Facilities & Improvements; Supervisor of Fire & Automation; Supervisor of Building Maintenance; Safety Officer; Director of Security & Safety; Director of Pt. Care Services; and VP of Facilities reviewed the monthly elevator fire fighter service test documentation. The facility did not test the fire fighter service on a monthly schedule. The facilities test and documentation was every other month.

During the exit conference on March 26, 2014, the above findings were again acknowledged by the VP of Facilities; Director of Facilities; Director of Security; Nursing; Director of Quality; CNO; Director of In Pt. Adult M/S Med/Surg; COO; Director of ED; and Director of Care.

Fire fighter service is critical during an emergency and failing to test the elevators may cause harm to patients, staff and visitors.