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Based on observation and interview, the facility failed to ensure there were no impediments to closing 2 of 18 doors protecting corridor openings in the first floor main exit corridor. This deficient practice could affect all occupants in the main first floor entry/exit corridor where no patient rooms are located.

Findings include:

Based on observation during a tour of the facility with the maintenance director on 04/06/10 at 12:35 p.m., corridor doors to the Health Information Services office and the pathologist's office were prevented from closing by wooden wedges. The maintenance director said at the time of observation, "I keep telling them they're not allowed."

This deficiency was cited on 02/10/10. The facility failed to implement a systemic plan of correction to prevent recurrence.

Based on observation and interview, the facility failed to ensure 2 of 2 third floor and 1 of 1 basement level exit corridors were free of all obstructions which could interfere with their full and instant use. This deficient practice could affect 17 staff observed on the basement level and 19 patients on the third floor.

Findings include:

1. Based on observation during a tour with the maintenance director between 12:30 p.m. and 1:30 p.m. on 04/06/10, the following fire exit corridors were used for storing supplies and equipment which was not in use:
a. In the main east west corridor on the third floor; portable computers on stands, overbed tables, a hall tree, wheel chair and EKG machine. This equipment lined one wall of the corridor with the hall tree on the opposite side of the corridor.
b. A second "L shaped" six foot wide, third floor corridor exitway from a patient treatment/office area into the main exit corridor was used for the storage of a linen cart, overbed table and medical supplies in a dead end alcove approximately six feet by five and one half feet. The IV medicine supply room was open into the exit way where the door had been removed. The maintenance director said at the time of observation, "if I put a smoke detector over the storage area, would it be OK (to use the exit way as a storage area) ?"

2. Based on observation during a tour with the maintenance director between 12:30 p.m. and 1:30 p.m. on 04/06/10, a bundle of cardboard cartons and a four by four foot wooden pallet stacked with cardboard cartons wrapped in plastic were located on the floor in the basement level exit corridor. The maintenance director said at the time of observation, "they'll be gone in an hour". No comment was made as to why the materials were left there.

This deficiency was cited on 02/10/10. The facility failed to implement a systemic plan of correction to prevent recurrence.

Based on observation and interview, the facility failed to ensure 1 of 8 reserve cylinders of nonflammable gases such as oxygen were properly chained or supported in a proper cylinder stand or cart. NFPA 99, Health Care Facilities, 8-3.1.11.2(h) requires cylinder or container restraint shall meet NFPA 99, 4-3.5.2.1(b)27 which requires freestanding cylinders be properly chained or supported in a proper cylinder stand or cart. This deficient practice affects anyone in the northwest parking area adjacent to the bulk reserve oxygen storage area.

Findings include:

Based on observation during a tour of the facility with the maintenance director on 04/06/10 at 12:45 p.m., one oxygen cylinder stood six inches from larger cylinders on both sides. The larger cylinders were secured with a chain. However, the same chain was too high to provide support for the smaller oxygen cylinder. The maintenance director said at the time of observation, all cylinders should have been provided with support.

This deficiency was cited on 02/10/10. The facility failed to implement a systemic plan of correction to prevent recurrence.