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Based on observation and staff interview, the facility failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition. In the event of a fire, all staff and patients may be affected.

Findings include:

On 04/13/2016 at 11:52 am, observation revealed the Fire Department Connection sign was not visible due to Medical Gas Pipe obstructing the view of the sign from the street.

Ref: 2002 NFPA 25 Section 12.7.1 (d)

Staff Member A and M confirmed findings at the time of discovery.

Based on observation and staff interview, the facility failed to ensure that fire extinguishers were installed correctly. In the event of a fire, staff and patients in the immediate area may be affected if the fire extinguishers are not installed properly.

Findings include:

On 04/13/2016 at 11:59 am, observation revealed a fire extinguisher that was placed on the floor instead of being properly installed so that the top of the extinguisher is no more than 5 feet above the floor, and in no case shall the clearance of the bottom of the fire extinguisher and the floor be less than 4 inches.

Ref: 2002 NFPA 10 Section 1.5.10

Staff Member A and M confirmed findings at the time of discovery.

Based on observation and staff interview, the facility failed to provide a precautionary sign for the oxygen storage room with the correct wording. In the event of a fire, this could place the patients and staff members in the immediate area at risk.

Findings include:

On 04/13/2016 at 11:49 am, observation revealed sign for the Medical Gases Room was not provided with a warning sign with the proper wording, "CAUTION: OXIDIZING GAS(ES) STORED WITHIN. NO SMOKING".

Ref: 2012 NFPA 99 Section 11.3.4.2.

Staff Members A and M confirmed findings at the time of discovery.

Based on observation and staff interview, the facility failed to maintain electrical wiring and equipment in accordance with the National Electrical Code. In the event of a fire, this could place patients and staff in the immediate area at risk.

Findings include:

On 04/13/2016 from approximately 10:00 am - 2:00 pm, observation revealed that surge protection devices in the following areas were lying unsecured on the floor:

In the CNO Office, the surge protection device lying unsecured on the floor next to a computer desk.
Behind the soda dispensing machines located near the CT Room.
In the Purchasing Office located near the O/R.

Ref: 2013 NFPA 70B Section 10.3.5.1.


Staff Members A and M confirmed findings at the time of discovery.