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Based on observation and staff interview the hospital did not ensure that the exits are readily accessible at all times in accordance with section 7.1. 19.2.1

Findings include:

During tours of the hospital at various times in the period from 1/10- 1/1/14/2013, the followings were identified in the presence of the Director of Fire Safety and the Director of Maintenance and Engineering who promised to correct the deficiencies:

1. The hallway of the endoscopy suite was partially blocked by two supply carts and two supply cabinets. Only three feet of the exit way was available for stretchers and evacuation in the event of an emergency or fire.
2. The hospital stored items very close to the ceiling in the sprinkled room and didn not leave a space of > 18 inches in the general storage room next to room 7.
3. The exit door near to the kitchen was observed to be blocked by an empty box and a safety cone which impeded the closure of the door.

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Based on observation and staff interview the hospital did not ensure that the Exit and directional signs are displayed in accordance with section 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1

Findings include:

During tours of the hospital at various times in the period from 1/10- 1/14/2013, the following were identified in the presence of the Director of Fire Safety and the Director of Maintenance and Engineering:

1. No illuminated exit signs were found in the clean preparation area.

2. No illuminated exit signs were found in the preparation and assembly area of the kitchen.

Based on observation and staff interview the hospital did not ensure that the exits are readily accessible at all times in accordance with section 7.1. 19.2.1

Findings include:

During tours of the hospital at various times in the period from 1/10- 1/1/14/2013, the followings were identified in the presence of the Director of Fire Safety and the Director of Maintenance and Engineering who promised to correct the deficiencies:

1. The hallway of the endoscopy suite was partially blocked by two supply carts and two supply cabinets. Only three feet of the exit way was available for stretchers and evacuation in the event of an emergency or fire.
2. The hospital stored items very close to the ceiling in the sprinkled room and didn not leave a space of > 18 inches in the general storage room next to room 7.
3. The exit door near to the kitchen was observed to be blocked by an empty box and a safety cone which impeded the closure of the door.

-

Based on observation and staff interview the hospital did not ensure that the Exit and directional signs are displayed in accordance with section 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1

Findings include:

During tours of the hospital at various times in the period from 1/10- 1/14/2013, the following were identified in the presence of the Director of Fire Safety and the Director of Maintenance and Engineering:

1. No illuminated exit signs were found in the clean preparation area.

2. No illuminated exit signs were found in the preparation and assembly area of the kitchen.