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Based on observation and interview with staff it was determined the facility failed to ensure that emergency exits did not pass through any intervening rooms or spaces other than corridors or lobbies. Failure to ensure safe egress during an emergency could cause harm to patients and staff.

NFPA 101, Life Safety Code, 2012. Chapter 19 Section 19.2.5.4 "Intervening Rooms or Spaces. Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies." Section 7.5.2.1 "Access to an exit shall not be through kitchens, store-rooms other than as provided in Chapter 36 and 37, restrooms, workrooms, closets, bedrooms or similar spaces, or other rooms or spaces subject to locking, unless passage through such rooms or spaces is permitted for the occupancy by Chapter 18, 19, 22, or 23."

Findings include:

The Plant Operations and the surveyor observed on May 08, 2019, an original corridor was converted into a storage room for supplies during a remodel, and an emergency exit sign remained in the storage room after the remodel.

The Plant Operations, Safety Officer/Emergency Management Coordinator, Assistant Director of Facility Services, and Chief Nursing Officer acknowledged during the exit conference on May 09, 2019, an original corridor was converted into a storage room for supplies during a remodel, and an emergency exit sign remained in the storage room after the remodel.

Based on observation and interview, it was determined the facility failed to ensure that staff did not use daisy chain power strips. The use of daisy chained power strips 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.

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:

The Plant Operations and the surveyor observed on May 08, 2019, the following power strips in the facility daisy chained or appliances were plugged into a power strip and not directly plugged into the receptacle wall outlets.

1. MIS room- a power strip was plugged into a UPS unit.
2. Business Office- a power strip was daisy chained into another power strip.
3. Medical records- a power strip was daisy chained into another power strip.
4. Business Office- a refrigerator was plugged into a power strip.
5. Medical Records- a refrigerator was plugged into a power strip.

The Plant Operations, Safety Officer/Emergency Management Coordinator, Assistant Director of Facility Services, and Chief Nursing Officer acknowledged during the exit conference on May 09, 2019, the power strips in the facility were daisy chained and/or appliances were plugged into a power strip and not directly plugged in to the receptacle wall outlets.

Based on observation and staff interview, it was determined the facility failed to keep combustible material 5 ft away from oxygen storage. Failure to keep combustible material away from oxidizing gases could cause an increase to the fire load which could harm staff and patients.

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 11.3.2.3 "Oxidizing gases, such as oxygen and nitrous oxide shall be separated from combustibles materials by one of the following:

(1) Minimum distance 20 feet
(2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
93) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/2 hour."

Findings included:

The Plant Operations and the surveyor observed on May 08, 2019, the storage of combustible material within 5 ft of oxygen storage in the Clean Utility room located in PACU.

The Plant Operations, Safety Officer/Emergency Management Coordinator, Assistant Director of Facility Services, and Chief Nursing Officer acknowledged during the exit conference on May 09, 2019, the storage of combustible material within 5 ft of oxygen storage in the Clean Utility room located in PACU.