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Based on observation and interview, the facility failed to provide testing for the operating room's emergency lighting and document the battery backup emergency lighting testing. Failure of these units during a power outage could cause harm to the patients by allowing the operating rooms to go dark during a surgery.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.9.1 "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " Section 7.9.3.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional Testing shall be conducted monthly with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds except as otherwise permitted by 7.9.3.1.1.(2) The Test interval shall be permitted to be extended beyond 30 days with the approval of authority having jurisdiction.(3) Functional testing shall be conducted annually for a minimum of 1/1/2 hours if the emergency lighting system is battery powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

Findings include:

During observation while on tour conducted on February 25, 2025 in Operating Rooms 1, 2, 3, 4, 5, 6, 7, 8 and 9, no designated emergency lighting could be identified. In an interview conducted on February 26, 2025, Employee #14 was asked if there was emergency lighting in the operating rooms and if so, where the emergency lighting could be found. Employee #14 stated that he/she was unaware of the location of emergency lighting but stated the lights do stay on when the generator is exercised.

Employee's #10 and #14 confirmed during the exit interview that there was not any emergency lights in the ORs

Based on observation while on tour, interview, and review of facility documentation, it has been determined the facility has failed to ensure the laboratory has utilized chemicals in compliance with NFPA 45 by ensuring laboratory hood maintenance and safety. Failure to comply with NFPA 45 guidelines can result in unnecessary chemical exposure to staff and fire hazard in the laboratory.

NFPA 45 (2011), Section 7.14.2 indicated: "...When installed or modified and at least annually thereafter, chemical fume hoods, ductless fume hoods, chemical fume hood exhaust systems, and laboratory special exhaust systems shall be inspected and tested as applicable, as follows...Visual inspection of the physical condition of the hood interior, sash, and ductwork...."

Findings include:

During observation while on tour conducted on February 25, 2025, three (3) laboratory hoods were observed within the laboratory bearing PM (preventative maintenance) stickers with a test date of February 15, 2024. A rubber gasket on the right side of one of these hoods intended to enclose power cords was worn out and could no longer enclose the cords on the laboratory hood.

A current PM for the laboratory hoods was requested but could not be provided.

Employee #10 acknowledged the deficiency while on tour on February 25, 2025. During an exit interview conducted on February 26, 2025, members of administration staff acknowledged the deficient practice.

Based on observation while on tour and interview, the hospital failed to ensure cooking equipment that collects grease were being cleaned on a regular basis. Failing to inspect and clean cooking equipment that collects oil and grease buildup can result in a kitchen fire, increasing the likelihood of harm to patients and/or staff.

NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.3.2.5, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial Cooking Equipment" "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations.... Chapter 11, Section 11.7.2 Cooking Equipment Maintenance indicated: "...Cooking equipment that collects grease below the surface, behind the equipment, or in the cooking equipment flue gas exhaust, such as griddles or char broilers, shall be inspected and, if found with grease accumulation, cleaned by a properly trained, qualified and certified person acceptable to the authority having jurisdiction...."

Findings include:

Observations made while on tour on February 25, 2025, revealed the following;

Multiple appliances including, but not limited to, the deep fat fryer, and the commercial range, had buildup of grease, food, and in the case of what appeared to be a commercial kettle, also a soiled cloth, on and around the appliances, including the outlets the equipment was plugged in to.

Employee #10, who accompanied Compliance Officers on tour, acknowledged the presence of the grease and debris. In an exit interview conducted on February 26, 2025, members of administrative staff acknowledged the deficient practice.

Based on observation and interview, it has been determined that the facility failed to install fire extinguishers near the generators and failed to maintain access to fire extinguishers in the operating rooms. Failure to provide and maintain access to fire extinguishers in key areas of the hospital can result in the likelihood of the spread of a fire in the event of a fire due to lack of fire prevention options, leading to increased possibility of harm to patients and to 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." 9.7.4 Manual Extinguishing Equipment. 9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10 2010 Edition 6.3.1.1 Minimum sizes of fire extinguishers for the listed grades of hazard shall be provided in accordance with Table 6.3.1.1, 6.3.1.2 Fire extinguishers shall be located so that the maximum travel distances do not exceed those specified in Table 6.3.1.1. NFPA 30 2012 edition 4.2.2 Combustible liquids Any liquid that has a closed cup flash point at or above 100 f as determined by the test procedures and apparatus set forth in section 4.4 NFPA 10 2012 edition 5.2.2 Class B fires are fires in flammable liquids, combustible liquids, petroleum greases, tars, oils, oil-based paints, solvents, lacquers, alcohols, and flammable gases. 6.3.1 Other Than for Fires in Flammable Liquids of Appreciable Depth. 6.3.1.1 Minimum sizes of fire extinguishers for the listed grades of hazard shall be provided in accordance with Table 6.3.1.1, except as modified by 6.3.1.5. Table 6.3.1.1 Fire Extinguisher Size and Placement for Class B Hazards...Type of Hazard...Basic Minimum Extinguisher Rating...Maximum Travel Distance to Extinguishers...(moderate)...20-B...50 ft...."

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:

Observations made while on tour on February 25, 2025, revealed the following:

There was not a fire extinguisher installed within 50 feet of the generator.

Fire extinguishers with obstructed access were found in the following areas:

1) One extinguisher in the laboratory
2) One extinguisher in OR 1
3) One extinguisher in OR 3
4) One extinguisher in OR 4
5) One extinguisher in OR 6
6) One extinguisher in sterile storage in the operating room area

While on tour, Employee #1 confirmed there was no fire extinguisher within 50 feet of the generators and Employees #10 and 14 acknowledged the extinguishers were obstructed in the operating rooms.

Based on observation, interview and review of facility documentation, it has been determined the facility has failed to maintain HVAC equipment. Failure to maintain HVAC equipment can result in aggravation to patients' medical conditions and discomfort for patients and staff.

NFPA 101 Life Safety Code, 2012 Edition Chapter 19, Section 19.5.2, "Heating Ventilating and Air Conditioning." Section 19.5.2.1 "Heating, ventilating and air conditioning shall comply with the provisions of section 9.2 and shall be installed in accordance with the manufacture's specifications" Section 9.2.1 " Air Conditioning, Heating, Ventilating, Ductwork, and Related Equipment." Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 91.

NFPA 91 Standard for Exhaust Systems for Air Conveying of Vapors, Gases, Mists, and Particulate Solids, Chapter 10, Maintenance Program, Section 10.6.1 indicated, "....All system components shall be maintained in good operating condition...." Section 10.6.5 indicated: "...Serious deficiencies shall require immediate attention...."

Findings include:

Based on observation while on tour, review of facility documentation and interview, the Department has determined the Administrator failed to ensure that the hospital HVAC systems were maintained in working order. Failure to ensure that the HVAC system is maintained in working order can result in discomfort for staff and patients and can result in adverse outcomes for patients.
Findings include:

Air Handler Unit 4/VFD (Variable Frequency Drive)

Document titled, " ...Event Report ...." revealed: " ...Occurrence Date ...01/06/2025 ...Report Date ...01/16/2025 ...Nature of Service Failure ...Temperature of Environment ...Description of event ...01-26-2025 Sorry computer crashed ...It was freezing cold ...had one blanket but wanted another blanket ...Patient was on the floor in the ED with only one blanket ...Offer our sincere apologize [sic] ...Investigation findings ...02-03-2025 ED was on Red level surge and staffing issues, we attempt to do our best ...02-05-2025 ...Thanks for your review ...." " ...Northwest Medical Center Request ...." documents revealed: Dated 09/25/2024: " ...Temp controller broken ...ED 9 ...Room is not warming up; thermostat hissing and not adjusting ...comments ...replaced t-stat ...." Dated 10/31/2024: " ...Check damper, thermostat not working blows cold air ...ED offices ...comments ...opened damper ...." Dated 10/31/2024: " ...ED Ancillary very cold ...comments ...opened damper ...." Dated 01/20/2025: " ...Cold offices in ED Admin hall. Check all t-stats. See floor plan ...Raised ahu temp ...." Dated 01/31/2025: " ...ER rooms 9, 10 and 15 are too cold ...comments ...Raised AHU temp ...." A tour was conducted of the Emergency Department on 02/20/2025 beginning at 10:33 a.m. The majority of staff observed in the Emergency Department while on tour were wearing jackets. Patients were observed to be lying in gurneys inside the ambulance entrance which registered the lowest temperature reading of 62.7°F. At this time, the outdoor temperature was 61°F. A total of 24 environmental temperatures were taken in the Emergency Department with the highest and the lowest temperatures removed.:
1. BH1-BH6 65.4
2. BH1-BH6 behind nurse's station 66.9
3. Outpatient entrance 67.6
4. Waiting room between outpatient and ER 66.3
5. Small waiting room, outpatient 65.8
6. Registration 66.2
7. Emergency room desk 64.7
8. Ancillary bed 3 65.6
9. Ancillary bed 9 65.8
10. 67.2 Hallway clean utility (ER)
11. Triage bed 2 66.0
12. Triage behind the ED desk 65.6
13. Exam Room 1 doorway 65.3
14. ER nurse's station 71.0
15. Ambulance entrance 62.7
16. ER Room 10 63.6
17. Room 14 65.3
18. Nurse's station by room 18 63.5
19. Room 19 64.2
20. Room 23 64.2
21. Room 27 64.2
22. Room 28 63.3
23. Room 30 64.2
24. Check-out desk 69.9

The average of 22 temperatures taken in the Emergency Department was 65.2°F. The lowest and the highest temperatures were removed prior to temperatures being averaged. Upon return to Northwest Medical Center on February 26, 2025, Employees #1 and #10 indicated a desire to utilize their own temperature gun. A side-by-side test was conducted throughout the hospital which indicated the calibrated gun utilized by Northwest Medical Center staff monitored temperature at about 2 degrees higher. Had this temperature gun been utilized, it is possible the average temperature would have instead registered at 67.2°.

An interview was conducted with Employee #1. Employee #1 stated that the VFD (Variable Frequency Drive) had died and it had taken six weeks to get a needed part. Employee #1 stated they had wanted to initiate the repair but a "cold snap" had occurred and because the repair would have required the VFD to be non-operational for four (4) hours, Employee #1 deferred the repair for when the weather improved. Employee #1 stated that until then the VFD was put at a constant fan speed. Compliance Officer asked, wouldn't a constant fan speed have made the environment colder? Employee #1 explained that it was better to have the VFD on than off and the temperature could still be controlled. Employee #1 stated that the central computer, known as the Building Automation System (BAS) monitored the temperature; however, the temperature was set by the staff. Employee #5 stated he/she set the temperature in the 50s "because we are in Arizona." Employee #1 stated that the temperature was checked daily and adjustments could be made manually. Compliance Officer asked if these daily temperatures were logged, and initially Employee #1 stated they were logged and could be provided but later Compliance Officer was informed there was no historical data available. Compliance Officer asked what was being done when work orders were being received and/or complaints regarding the temperature being too cold. Employee #1 stated an employee would be sent to see if there was an actual temperature issue and if there was, the first line of defense was to check the thermostats to see if there was a thermostat not functioning properly. If not, other adjustments could be made.

A subsequent interview was conducted on February 26, 2025 with Employee #13 who stated, "We didn't ignore the problem." Employee #13 confirmed that adjustments were made in response to employee complaints. Employee #13 indicated he/she had noted some of these temperature adjustments and provided a copy of handwritten notes indicating temperature adjustments made to the CT (computed tomography) room, twice on 11/20/24, once on 11/22/24, once on 12/2/24, once on 12/3/24 and once on 12/5/24; however, the CT room is in a separate area than the Emergency Room and Outpatient and the complaints verbalized by the staff of CT was that the temperature was too warm. Two additional temperature adjustments were noted by Employee #13 on 12/4/24 and 01/09/25, but the location of these temperature adjustments were not logged.

Email communications regarding the VFD repairs revealed the following: From third-party service to Employee #1 dated 12/30/2024: " ...See below for the dates we have available for the installation for the VFD on AHU 4 ...1/9 ...1/10 ...Or any day between 1/14-1/16 ...This will be approx ...4-hour shutdown ...." From Employee #5 to third-party service dated 12/31/2024: " ...We will need to put HEPA filters and fans in the space during the shut down ...." On February 5, 2025 at 8:55 a.m., Employee #5 contacted third-party service regarding a different repair. Third-party service responded at 9:28 a.m. with this question: " ...Hate to keep asking but when do you want to do the VFD on AHU3. Everything is on site waiting for a shutdown ...." Employee #5 9:31 a.m. response: " ...AHU3-Is this 3 (Cath lab) or 4 (ED)?...." Third-party service 9:33 a.m. response: " ...Women's center AHU4 ...." Employee #5 9:37 a.m. response ...How long do you need to do the repair?...." Third-party service 9:38 a.m. response: " ...4 hrs ...." Employee #5 9:52 a.m. response: " ...My team is telling me this should be AHU for the ED. We do not have VFD issues at the WC. How much notice do you need? The weather is much warmer this week ...."

Third-party service 11:40 a.m. response: " ...This was an old job that we've been trying to get closed out but wasn't being allowed to do the work. See attached ...." Employee #5 12:04 p.m. response: " ...So what POs do we still have open? Do we need to regroup?...AHU4-ED needs new VFD ...." Third-party service response: " ...We probably need to sit down and go over open items. We can set something up later this week or next week ...."

Heat Exchanger/Hot Water Pump

In the interview with Employee #1, Employee #1 further explained that the hospital heating hot water system also required repair but had not yet been repaired because Employee #1 was waiting for parts from third-party service. Employee #5 expected the repair to be executed on Tuesday, February 25. Employee #1 provided a summary which indicated: " ...Background ...The heating system runs on steam and hot water. The steam is generated in the boilers and sent to a heat exchanger. This heat exchanger is where the steam transfers its heat to the heating water system. The heating water is then pumped out to the floors to fan oil units and air handlers to keep occupants warm. This system consists of one heat exchanger and two pumps ...Assessment ...The tubes that separate the steam from the water inside the heat exchanger are corroded. We know this because we are getting steam in our heating water system. This overheating and steam in the wrong pipes cause system and pump failure. Pump #1 has been damaged by the excessive heat and needs to be replaced. We are currently only running on Pump #2 ...." " ...TDI Industries ...." Scope of Work dated October 22, 2024 revealed: " ...NWMC-CP1 Replace HWP-2 & Seal Replacement for HWP-1 ...." Scope of Work dated October 10, 2024 revealed: " ...NWMC CP1, West HX Repairs ...." Scope of Work dated October 10, 2024 revealed: " ...NWMC Replace HX-1 Tube Bundles with gaskets ...." Email from third-party service to Employee #5 dated 02/18/2025 indicated: " ...This is scheduled for next Tuesday for the installation of the heat changer ...."

An attempt was made to repair the heat changer on February 25, 2025, but the HX-1 tube bundle arrived damaged and could not be installed.


Boiler #2

On September 29, 2022, Factory Mutual Insurance Company conducted an inspection and indicated in a report dated October 1, 2022 that Boiler #2 had leaking and warped tubes.

On November 7, 2022, Employee #1 sent an email to Employee #15 to discuss repairs that needed to be made to the hospital. Employee #1 stated: " ...Also, we just found out, and are waiting for the official report, that boiler #2 needs to be replaced and cannot be rebuilt ...We have been told verbally that ...recommendation is for full replacement ...."

Employee #15 responded on November 8, 2022: " ...I have to get this finalized and submitted, so we must make some tough decisions. I think starting on the elevators and the boiler is the priority. A big part of our dilemma is that we have projects rolling over into 2023. In your case, there is currently $468,748 still waiting to be spent on Chiller 4. Essentially, I am having to pull this amount out of the '22 and '23 budgets! If you add that rollover amount to our proposed '23 budget, it means I am putting close to $1.5M into NMC Tucson which we really can't afford to do ....What is the absolute priority that can affect patient care and keeps you up at night?...."

On November 9, 2022, Employee #1 responded: " ...See details below. As we delay these projects we are creating a bottleneck of funds for future years to come. As we slowly tackle these big dollars issues more will arise just pushing the state of the aging and soon to be obsolete infrastructure down the road. ...I will take every dime you can send my way to help avoid, and improve,t he current state we are in at Northwest Medical ...McCcok [sic] has recommended that we replace boiler #2 for reasons stating in other emails ...The verbal estimate today is 600k ...Lead times are a couple of months and should be ready for install over the summer of 2023. Note-boiler #1 is the same age as boiler #2 ...."

Employee #15 responded on November 11, 2022 " ...Thanks ...You didn't answer my questions on how you want to prioritize. I am putting down the boiler #2 ...."

A Contractor Authorization to Proceed was issued on February 15, 2023. The boiler was installed December 27, 2023.

Based on observation while on tour, it has been determined the facility failed to appropriately label medical gas piping. Failure to appropriately label medical gas piping can result in confusion or error.

NFPA 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 5, Section 5.1.11.1 Pipe Labeling indicated: "...Piping shall be labeled by stenciling or adhesive markers that identify the patient medical gas, the support gas, or the vacuum system and include the following...Name of the gas or vacuum system or the chemical symbol per Table 5.1.11...Gas or vacuum system color code per Table 5.1.11...the operating pressure...Pipe labels shall be located as follows...At intervals of not more than 6.1m (20ft)...." 5.1.11.1.3 indicated: "...Medical gas piping shall not be painted...."

Findings include:

Observation while on tour conducted on February 25, 2025 in the medical vacuum/medical piping areas revealed medical gas piping that was painted pink, yellow, blue, white and green. Although the piping was observed to be labeled with stenciling indicating the purpose of the piping, this stenciling was not observed to occur every 20 feet.

Employee # 10 conformed while on tour that the Med gas piping was painted and not labeled properly.

Based on observation during the tour and interview, the facility failed to maintain electrical receptacles in patient areas and offices throughout the facility. Failure to maintain receptacles could result in them not working or electrical problems.

NFPA 101 Life Safety Code, 2012 Edition, Chapter 9, Section 9.1.2 "Electrical Systems. Electrical wiring and equipment shall be in accordance with NFAP 70, National Electrical Code, unless shch installations are approved existing installations, which shall be permitted to be continued in service." NFPA 70, 2011, Chapter 4, Section 406.6 Receptacle Faceplates (Cover Plates). Receptacle faceplates shall be installed so as completely cover the opening and seat against the mounting surface. Receptacle faceplates mounted inside a box having a recess mounted receptacle shall effectiviely close the opening and seat against the mounting surface."

Findings include:

Observation while on tour conducted on February 25, 2025, revealed:

-Two receptacles with broken covers in room 475
-One receptacle hanging by wires in Telemetry area
-One receptacle hanging by wires in Laboratory area
-One junction box in Laboratory under a desk missing a face plate
-One receptacle face plate missing in room near Operating Room 7
-Life safety receptacle installed over sink taped over with no explanation

In an interview conducted with Employee #10 while on tour, Employee #10 confirmed the findings. During an exit interview conducted on February 26, 2025, the deficient items were acknowledged by administrative staff.

Based on observation while on tour and interview, it was determined that the facility allowed the use of power strips but did not mount to the equipment in the operating rooms. Failure to properly use power strips and outlets could lead to electrical overload or fire, harming 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.

CMS S&C: 14-46-LSC- Life Safety Code surveyors assess the use of power strips in healthcare facilities. However, the following guidance is provided as reference for healthcare surveyors as they survey physical environment along with other CoP requirements. Any observed power strip deficiencies should be conveyed to the LSC surveyors for citation.
If line-operated medical equipment is used in a patient care room/area, inside the patient care vicinity:
o UL power strips would have to be a permanent component of a rack-, table-, pedestal-, or cart-mounted & tested medical equipment assembly
o Power strips providing power to medical equipment in a patient care room/area must be UL 1363A or UL 60601-1
o Power strips cannot be used for non-medical equipment
If line-operated medical equipment is used in a patient care room/area, outside the patient care vicinity:
o UL power strips could be used for medical & non-medical equipment with precautions as described in the memo
o Power strips providing power to medical equipment in a patient care room/area must be UL 1363A or UL 60601-1
o Power strips providing power to non-medical equipment in a patient care room/area must be UL 1363
If line-operated medical equipment is not used in a patient care room/area, inside and outside the patient care vicinity:
o UL power strips could be used with precautions
Power strips providing power to non-medical equipment in a patient care room/area must be UL 1363. In non-patient care areas/rooms, other UL strips could be used with the general precautions.

Findings include:

Observations conducted while on tour February 25, 2025 revealed that Operating Rooms 2, 3, 4, 6 and 9 had power strips that were not mounted to a rack, table, pedestal, or cart-mounted and tested medical equipment assembly.

Employees # 10 and #14 confirmed the improper use of power strips by not having them permanently mounted to equipment in the operating rooms.

Based on observation while on tour and interview, it has been determined the facility failed to ensure that positive-pressure gases are properly and securely stored. Failure to securely and properly store positive-pressure gases can result in a fire, leading to potential harm to patients or 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 11.2, Subsection 11.2.1 indicated, "...Cylinders and containers shall comply with 5.1.3.1...." Section 5.1.3.1, Subsection 5.1.3.3.2 Design and Construction indicated: "...Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements:...(3) If outdoors, they shall be provided with an enclosure (wall or fencing) constructed of noncombustible materials with a minimum of two entry/exits...New to the 2012 edition is this requirement for outdoor storage enclosures to have two entries/exits. This requirement is intended to address the situation where, if a person was in the enclosure and an event occurred taht prevented egress via the one opening, the person could exit via the other opening. The most common form in which this requirement will be implemented will be placing two gates in a chain-link fence surrounding a bulk system...."

NFPA 99 Section 5.1.3.1 Subsection A.5.1.3.3.2(7) indicated: "...They shall be provided with racks, chains, or other fastenings to secure all cylinders from falling, whether connected, unconnected, full, or empty...Paragraph 5.1.3.3.2 (7) is a change to the 2002 requirement for individual securing of the cylinders. In the 2005 edition, the standard returned to the more relaxed "secure all cylinders" which permits, for instance, the single chain around multiple cylinders, which was common practice prior to the 2002 edition...Exhibit 5.3 illustrates two arrangements: one in which the cylinders are secured properly, and one in which the cylinders are not secured properly...."

Findings include:

During observation while on tour on February 25, 2025, four outdoor medical gas enclosures were observed: one area where nine (9) CO2 canisters were connected to a regulator outdoors located next to the main hospital building, and three separate but connected enclosures behind the hospital building constructed out of chain-link fencing that contained: 1) Bulk oxygen; 2) Assorted positive-pressure canistered medical gases; 3) empty canisters of medical gas and medical gas cabinets.

None of these enclosures had two entries and exits.

The photo pictured in NFPA 99 Exhibit 5.3 of improperly secured cylinders depicts seventeen (17) cylinders secured behind a single chain.

During observation while on tour conducted on February 26, 2025, within the outdoor medical gas enclosures, six (6) medical gas canisters were observed to be secured in a triangular formation by a single chain. Twenty-two (22) assorted medical gases were observed to be in a cluster formation and secured by a single chain. Two (2) canisters appeared to be unsecured.

In an interview conducted with Employee #10, Employee #10 confirmed that the outdoor enclosures did not possess two separate entries or exits. In an exit interview conducted on February 26, 2025, the deficient practices were acknowledged by administration staff.