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Based on observation and interview, the facility did not ensure that the stair shaft is maintained in accordance with NFPA 101 (2012 edition) Sections 19.2.2.3 and 7.2.2.5.3. This deficient practice could affect all patients, as well as an undetermined number of staff and visitors.

Findings include:

On 09/13/2022 at 12:44 pm, observation at the exit door of the stairwell beside the Administration suite, revealed the stairwell was being used for storage of a shovel.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff J and Staff K.

Based on observation and staff interview, the facility did not maintain clear access to exits free of obstructions in accordance with NFPA 101 19.2.1, 7.1.10.2.1. The deficient practice could affect an undetermined number of staff and visitors.

Findings include:

On 09/13/2022 12:45 pm, observation in the maintenance exit access corridor outside of Storage 0116, in excess of 20 upholstered chairs were stored along the wall between the corridor and storage room. Additionally, a six foot long table with more than a dozen IV pumps on it was against the wall of the corridor near the stair.

This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff J and Staff K.

Based on observation and interview, the facility failed to install smoke alarm devices in locations per NFPA 101 (2012 edition) Sections 19.3.4.2.1, 9.6.2.1, and 33.2.3.4.3. This deficient practice has the potential to affect 2 staff.

Findings include:

On 09/14/2022 at 9:36 am, observation in the On-Call rooms revealed that the rooms did not include a smoke alarm for detection of smoke and notification of the occupant.

This deficient condition was confirmed at the time of discovery by a concurrent interview with Staff J and Staff K.

Based on observation and interview, the facility failed to provide room pressure relationships required by NFPA 101 (2012 edition) Sections 19.5.2.1, 9.1.3, 9.3.1.1 and ASHRAE 170, Table 7.1. This deficient practice could affect all emergency room patients, as well as an undetermined number of staff and visitors.

Findings include:

On 09/14/2022 at 9:53 am, observation in the emergency department at Trauma 2 revealed that the room pressure differential between the room and surrounding areas was being maintained as a negative pressure. Positive pressure is required in Trauma rooms.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff J and Staff K.

Based on observation and interview, the facility did not sign oxygen storage rooms in accordance with NFPA 101 (2012 edition) Sections 19.3.2.4; NFPA 99 (2012 edition) Sections 11.3.4 . This deficient practice could affect all patients, as well as an undetermined number of staff and visitors.

Findings include:

On 09/13/2022 at 1:19 pm, observation at the oxidizing gas cylinder storage room revealed that there was no "CAUTION: OXIDIZING GAS(ES) STORED WITHIN; NO SMOKING" sign visible from a distance of 5 feet.

This deficient practice was confirmed at the time of discovery by a concurrent interview with Staff J and Staff K.