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Based on observation and interview, the facility did not provide a common separation wall with sealed wall penetrations, as required by with NFPA 101 (2012 edition), 4.6.12, 39.1.3, 6.1.14.3.1, 6.1.14.3.2, 6.1.14.4; and 8.2.1.3. This deficiency had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 11/13/2018 at 10:00 am, it was observed in the Physician Center Building in the Physical Therapy smoke compartment on the second level floor in the corridor to OPC at the 1 hour wall above the ceiling, that penetrations were not properly fire stopped according to an approved method. The deficiency included a 3" x 4"opening and a 2" diameter sleeve, and (2) 1/2"diameter conduits with data wires that were not properly fire stopped. The condition was confirmed at the time of discovery by a concurrent interview with staff Z (Facilities Supervisor), staff V (Safety Officer) and staff W (Emergency Preparedness & Hazardous Material Coordinator).

Based on observation and interview, the facility failed to maintain building construction type. Building construction type and stories as required by NFPA 101 (2012 edition), Sections meets Table 19.1.6.1, unless otherwise permitted by by NFPA 101 (2012 edition), Sections 19.1.6.2 through 19.1.6.7. This deficient practice could affect all patients as well as an undetermined number of staff and visitors.

Findings include:

On 11/12/18 at 1:10 PM, observation revealed that the construction type was not being maintained in the Penthouse. The steel beam web was missing spray fireproofing material for approximately 10' above unit heater #3 and #4. The condition was confirmed at the time of discovery by concurrent interview with Staff Z (Facility Supervisor) and Staff Y (Patient Care Manager).

Based on observation and interview, the facility failed to maintain Exit Signage in accordance with the requirements of NFPA 101 - 2012 edition, sections 19.2.10.1 and 7.10.
Exit and directional signs are displayed in accordance with continuous illumination also served by the emergency lighting system. This deficient practice could affect all of the patients, as well as an undetermined number of staff and visitors.

Findings include:

On 11/12/18 at 1:30 PM, observation revealed in the Penthouse that an exit sign was missing at the exit door. The condition was confirmed at the time of discovery by concurrent interview with Staff Z (Facility Supervisor) and Staff Y (Patient Care Manager).

Based on observation and interview, the facility failed to provide sprinkler coverage and install sprinklers in accordance with the requirements of NFPA 101 - 2012 edition, Sections 40.3.2, 40.3.2.1, 40.3.2.2 and 9.7: NFPA 13 - 2010 edition sections 8.15.10.3 and 8.6.5.2.1.1. These deficiencies had the potential to affect an undetermined number of inpatients, staffs and visitors.

Findings include:

1. On 11/12/2018 at 2:35 PM, observation revealed in the 1st Floor High Voltage Room, that the electrical equipment room did not have sprinkler protection and was separated with a 2 hour rated fire barrier but was also used for storage. Combustible cardboard boxes and left over equipment were stored inside the electrical equipment room.

2. On 11/12/2018 at 2:40 PM, observation revealed in the 1st Floor High Voltage Transfer Switch Room, that the electrical equipment room did not have sprinkler protection and was separated with a 2 hour rated fire barrier but was also used for storage. Combustible cardboard boxes and wooden crates were stored inside the electrical equipment room.

These deficient practices were confirmed by Staff BB (Operations Specialist), Staff CC (Project Manager) & Staff DD (Director of Facilities) at the time of discovery.

Based on observation and interview, the facility failed to maintain hazardous areas in accordance with the requirements of NFPA 101 - 2012 edition, sections 19.3.2.1 and 8.4. These deficiencies had the potential to affect an undetermined number of inpatients, staffs and visitors.

Findings include:

1. On 11/12/18 at 2:22 PM, observation revealed on the third floor in the Med Surgical smoke compartment that the door leading to the soiled utility room #3302C1 was not in a closed position. The condition was confirmed at the time of discovery by concurrent interview with Staff Z (Facility Supervisor) and Staff Y (Patient Care Manager).

2. On 11/12/18 at 4:03 PM, observation revealed on the third floor in the Labor and Delivery smoke compartment that the door leading to the storage room #3211C did not have a closer. The condition was confirmed at the time of discovery by concurrent interview with Staff Z (Facility Supervisor) and Staff Y (Patient Care Manager).



29942

Based on observation and interview, the facility did not maintain a hazardous area in accordance with the requirements of NFPA 101 - 2012 edition, sections 19.3.2.1, 19.3.2.1.2, 19.3.2.1.3 and 8.4. This deficiency had the potential to affect an undetermined number of patients, staff and visitors.

Findings include:

On 11/13/2018 at 10:15 am, observation revealed in the 1st Floor Corridor Alcove in front of the MRI & CT Scan roof, that the hazardous room was protected with a sprinkler system but was not smoke tight. The hazardous room was open to the corridor system. Four large combustible cardboard boxes were stored in the corridor alcove.

This deficient practice was confirmed by Staff Z (Facility Supervisor), Staff Y (Patient Care Manager), Staff CC (Project Manager) & Staff DD (Director of Facilities) at the time of discovery.

Based on observation and interview, the facility did not provide battery powered emergency lights in an anesthetizing location in accordance with the requirements of NFPA 101 (2012 edition), Section 19.3.2.3 , NFPA 99 (2012 edition), Section 6.3.2.2.11.1, 6.3.2.2.11.2, 6.3.2.2.11.3 & 6.3.2.2.11.4. This deficiency had the potential to affect an undetermined number of patients, staff and visitors.

Findings include:

On 11/13/2018 at 10:25 am, observation revealed in the 1st Floor GI Area Procedure room number 1315 that the procedure room was used to administer general anesthesia and deep sedation, and one or more battery powered lighting units were not provided inside this procedure room.

This deficient practice was confirmed by Staff Z (Facility Supervisor), Staff Y (Patient Care Manager), Staff CC (Project Manager) & Staff DD (Director of Facilities) at the time of discovery.

Based on observation and interview, the facility did not identify the fire alarm panel power source as per NFPA 101 (2012 ed.), 9.6.1.3 and NFPA 72 (2010 ed.), 10.5.5.2.1. This deficiency had the potential to affect 59 of 59 residents and an undeterminable number of staff and visitors.

FINDINGS INCLUDE:

On 11/12/2018 at 3:00 PM, observation revealed in the Partial Basement level Maintenance Shop Room, that the fire alarm power circuit disconnecting information was not permanently identified at the main fire alarm control panel.

This deficient practice was confirmed by Staff BB (Operations Specialist), Staff CC (Project Manager) & Staff DD (Director of Facilities) at the time of discovery.

Based on observation and interview, the facility failed to maintain Fire Alarm System - Initiation in accordance with the requirements of NFPA 101 - 2012 edition, sections 18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5.
Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations or other continuously attended staff locations, provided alarm boxes are visible, continuously accessible, and 200' travel distance is not exceeded. This deficient practice could affect all of the patients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 11/12/18 at 1:40 PM, observation revealed in the Penthouse that the duct smoke detector was missing the cover. The location of the duct smoke detector was at the L1D10 duct. The condition was confirmed at the time of discovery by concurrent interview with Staff Z (Facility Supervisor) and Staff Y (Patient Care Manager).

Based on observation and interview, the facility did not provide visible and audible fire-alarm notification devices as required by NFPA 101 (2012 edition), Sections 19.3.4 and 9.6, and NFPA 72 (2010 edition), Sections 18.6. This deficiency had the potential to affect an undetermined number of patients, staff and visitors.

Findings include:

On 11/13/2018 at 10:35 am, observation revealed that visible fire alarm notification devices were not provided inside the 1st Floor GI Area Employee Locker Room.

This deficient practice was confirmed by Staff Z (Facility Supervisor), Staff Y (Patient Care Manager), Staff CC (Project Manager) & Staff DD (Director of Facilities) at the time of discovery.

Based on record review and interview, the facility did not perform the semi-annual testing and inspections of the fire alarm system in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.3.4 and 9.6.1.3 and NFPA 72 - 2010 edition, Sections 14.3.1 and 14.4.5. These deficiencies had the potential to affect all inpatients, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 11/12/2018 at 12:55 PM, review of the documents titled "Johnson Controls - Fire Alarm & Life Safety System Inspection Certificate" dated 6/18/2018 revealed that the semi-annual visual inspection of alarm initiating devices for smoke detectors, duct detectors, heat detectors, electromechanical releasing devices (door hold opens) and manual fire alarm boxes (pull stations) were conducted once, on 6/18/2018 by Johnson Controls within the last year.

2. On 11/12/2018 at 1:05 PM, review of the documents titled "Johnson Controls - Fire Alarm & Life Safety System Inspection Certificate" dated 6/18/2018 that the semi-annual visual inspection of alarm notification devices were conducted once, on 6/18/2018 by Johnson Controls within the last year

3. On 11/12/2018 at 1:08 PM, review of the documents titled "Johnson Controls - Fire Alarm & Life Safety System Inspection Certificate" dated 6/18/2018 revealed that the sealed lead acid type batteries for the Fire Alarm System were only tested once, on 6/18/2018 by Johnson Controls within the last year.

These deficient practices were confirmed by Staff BB (Operations Specialist), Staff CC (Project Manager) & Staff DD (Director of Facilities) at the time of discovery.

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 101 (2012 edition) 19.3.5, and 9.7, and NFPA 13 (2010 edition) 8.1 requirement with all rooms sprinkled when the code required full sprinkling. This deficiency had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 11/12/2018 at 2:00 PM, it was observed in the 2 North smoke compartment on the second floor in the 2 west electrical closet, that the closet was not sprinkler protected. The condition was confirmed at the time of discovery by a concurrent interview with staff T (Manager Plant Operations), staff V (Safety Officer), staff U (Director Women and Children's Services), and staff AA (Maintenance Mechanic).

Based on observation and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 101 - 2012 edition, Sections 19.3.5 and 9.7.5, NFPA 25 - 2011 edition. These deficiencies had the potential to affect an undetermined number of patients, staff and visitors.

Findings include:

1. On 11/12/2018 at 2:46 PM, observation and interview in the Labor and Delivery smoke compartment birthing and neonatal intensive care room revealed a gap surrounding the recessed can light. The condition was confirmed at the time of discovery by concurrent interview with Staff Z (Facility Supervisor) and Staff Y (Patient Care Manager).

2. On 11/12/2018 at 2:53 PM, observation and interview in the Med Surgical smoke compartment room #3145 revealed a 2' x 4' ceiling tile that was not in place. The condition was confirmed at the time of discovery by concurrent interview with Staff Z (Facility Supervisor) and Staff Y (Patient Care Manager).

3. On 11/12/2018 at 3:43 PM, observation and interview in the Med Surgical smoke compartment room #3208B revealed a continuous opening in the ceiling tile grid. The condition was confirmed at the time of discovery by concurrent interview with Staff Z (Facility Supervisor) and Staff Y (Patient Care Manager).

4. On 11/12/2018 at 3:50 PM, observation and interview in the Labor and Delivery smoke compartment room #3201B revealed an 1/2" gap in two ceiling tiles. The condition was confirmed at the time of discovery by concurrent interview with Staff Z (Facility Supervisor) and Staff Y (Patient Care Manager).






29942

Based on observation and interview, the facility did not maintain the automatic sprinkler system in accordance with NFPA 101 - 2012 edition, Sections 19.3.5 and 9.7.5, NFPA 25 - 2011 edition, Section 5.4.1.6. This deficiency had the potential to affect an undetermined number of patients, staff and visitors.

Findings include:

11/12/18 at 3:15 PM, observation revealed in the Partial Basement Floor Fire PUMP Room that the spare sprinkler storage cabinet did not have a special wrench for removal and installation of sprinklers. A plier was kept on the spare sprinkler head cabinet. The condition was confirmed at the time of discovery by concurrent interview with Staff BB (Operations Specialist), Staff CC (Project Manager) & Staff DD (Director of Facilities).


33398

Based on observation and interview, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25. The sprinkler system did not have sprinklers with intact escutcheon rings, as required by NFPA 101 (2012 edition), 9.7.5, and NFPA 25 (2011 edition). This deficiency had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 11/12/2018 at 1:44 PM it was observed in the 2 North smoke compartment on the second floor in room 2108 that the escutcheon plate was missing on the sprinkler head. The condition was confirmed at the time of discovery by a concurrent interview with staff T (Manager Plant Operations), staff V (Safety Officer), staff U (Director Women and Children's Services), and staff AA (Maintenance Mechanic).

Based on observation and interview, the facility failed to maintain Portable Fire Extinguishers in accordance with the requirements of NFPA 101 - 2012 edition, section 19.3.5.12 and NFPA 10.
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 101 (2012), Standard for Portable Fire Extinguishers. This deficient practice could affect all of the residents and an undeterminable number of staff and visitors.

Findings include:

On 11/12/18 at 12:55 PM, observation revealed a fire extinguisher was placed on the floor. The condition was confirmed at the time of discovery by concurrent interview with Staff Z (Facility Supervisor) and Staff Y (Patient Care Manager).

Based on observation and interview, the facility failed to maintain Corridors - Construction of Walls in accordance with the requirements of NFPA 101 - 2012 edition, 19.3.6.2, 19.3.6.2.7.
Corridors are separated from use areas by walls constructed with at least 1/2-hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the transfer of smoke. This deficient practice could affect all of the patients, as well as an undetermined number of staff and visitors.


Findings include:

On 11/12/18 at 3:35 PM, observation revealed on the third floor in the Labor and Delivery smoke compartment room 3204G that the corridor wall had an approximate 4" diameter opening with communication cables that was not sealed to resist the transfer of smoke . The condition was confirmed at the time of discovery by concurrent interview with Staff Z (Facility Supervisor) and Staff Y (Patient Care Manager).

Based on observation and interview, the facility did not maintain the corridor doors in accordance with the requirements of NFPA 101 - 2012 edition, sections 19.3.6.3.5. This deficiency had the potential to affect an undeterminable number of patients, staff and visitors.

Findings include:

1. On 11/12/2018 at 4:15 PM, observation revealed in the 1st Floor Day Surgery Area Room Number 1362C that the corridor door was held open with a chair.

This deficient practice was confirmed by Staff BB (Operations Specialist), Staff CC (Project Manager) & Staff DD (Director of Facilities) at the time of discovery.

2. On 11/13/2018 at 9:45 am, observation revealed in the 1st Emergency Area Exam Room Number 3 that the corridor door was held open with a Medicine IV cart.

3. On 11/13/2018 at 9:55 am, observation revealed in the 1st Emergency Area Exam Room Number 3 that the double corridor doors did not positively latch after three tries.

4. On 11/13/2018 at 10:00 am, observation revealed in the 1st Emergency Area Exam Room Number 4 that the double corridor doors did not positively latch after three tries.

5. On 11/13/2018 at 10:05 am, observation revealed in the 1st Emergency Area Exam Room Number 2 that the corridor door was held open with a large cart.

6. On 11/13/2018 at 10:45 am, observation revealed that the inactive leaf on the 1st Floor Pharmacy double doors was not automatically positive latching inside the Pharmacy Department. When the inactive leaf was not manually latched, both doors would not positively latch and stay closed.

These deficient practices were confirmed by Staff Z (Facility Supervisor), Staff Y (Patient Care Manager), Staff CC (Project Manager) & Staff DD (Director of Facilities) at the time of discovery.

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations as required by NFPA 101 (2012 edition), 19.3.7.3., and 8.5. This deficiency had the potential to affect an undetermined number of patients, staff and visitors.

FINDINGS INCLUDE:

On 11/13/2018 at 10:55 am, it was observed on the 1st floor near room number 1106G at the smoke barrier wall above the ceiling, that a bundle of wire penetration was not properly fire stopped according to an approved method.

This deficient practice was confirmed by Staff Z (Facility Supervisor), Staff Y (Patient Care Manager), Staff CC (Project Manager) & Staff DD (Director of Facilities) at the time of discovery.


33398

Based on observation and interview, the facility did not provide and maintain the fire-rating and smoke tightness of smoke barrier walls with sealed wall penetrations as required by NFPA 101 (2012 edition), 19.3.7.3., and 8.5. This deficiency had the potential to affect an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 11/12/2018 at 1:33 PM, it was observed in the 2 center smoke compartment on the second level floor in room 2107 at the smoke wall above the ceiling, that a penetration was not properly fire stopped according to an approved method. The deficiency included a 4" x 6" hole that was not properly fire stopped. The condition was confirmed at the time of discovery by a concurrent interview with staff T (Manager Plant Operations), staff V (Safety Officer), staff U (Director Women and Children's Services), and staff AA (Maintenance Mechanic).

Based on observation and interview, the facility failed to provide smoke barrier doors with 1-3/4 inch thick solid bonded wood-core doors or construction that resists fire for 20 minutes in accordance with NFPA 101 (2012 edition), 19.3.7.6 and 8.5. This deficient practice could affect all of the patients, as well as an undetermined number of staff and visitors.

Findings include:

On 11/12/18 at 2:00 PM, observation on the third floor corridor between Med Surgical smoke compartment and the Labor Delivery smoke compartment revealed a pair of wood double smoke barrier doors that did not prevent the passage of smoke between the compartments. The condition was confirmed at the time of discovery by concurrent interview with Staff Z (Facility Supervisor) and Staff Y (Patient Care Manager).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 101 (2012 edition) 19.5.1.1, 9.1.2, and NFPA 70, National Electrical Code (2011 edition) with enclosed raceways. This deficiency had the potential to affect 24 of the 51 patients, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

On 11/12/2018 at 2:25 PM, it was observed in the Med Surge smoke compartment on the second floor in the corridor to the North P. O. B. above the ceiling, that the electrical code was not followed. A 4"x 4" Junction box above the ceiling was missing a cover plate, so the electrical raceway system was not enclosed. The condition was confirmed at the time of discovery by a concurrent interview with staff T (Manager Plant Operations), staff V (Safety Officer), staff U (Director Women and Children's Services), and staff AA (Maintenance Mechanic).

Based on record review and interview, the facility did not conduct fire drills at varied times in accordance with the requirements of NFPA 101 (2012 edition), Section 19.7.1.4, 19.7.1.5, 19.7.1.6 and 19.7.1.7. This deficiency had the potential to affect all inpatients, as well as an undetermined number of staff and visitors.

Findings include:

On 11/12/2018 at 1:45 PM, review of the facility fire drill documents for the last 12 months revealed that fire drills on the NOC shift were not conducted at varied times. Two of four NOC shift (4th quarter of 2017 & 1st quarter of 2018) drills were conducted between 5:01 am and 5:10 am, and two of four NOC shift (2nd quarter of 2018 & 3rd quarter of 2018) drills were conducted between 11:38 PM and 12:15 am.

This deficient practice was confirmed by Staff BB (Operations Specialist), Staff CC (Project Manager) & Staff DD (Director of Facilities) at the time of discovery.

Based on observation and staff interview, the facility did not store soiled linen and trash collection receptacles greater than 32 gallons capacity in a properly separated hazardous storage areas as required by NFPA 101 - 2012 edition section 19.7.5.7. These deficiencies had the potential to affect an undetermined number of patients, staff and visitors.


Findings include:

1. On 11/13/2018 at 9:45 am, observation revealed one 20 gallon size trash receptacle and one 20 gallon size soiled linen receptacle were stored together in the 1st Floor Emergency Area Exam Room Number 10. These two trash and soiled linen receptacles together exceeded 32 gallons capacity in a 64 square foot area.

2. On 11/13/2018 at 10:15 am, observation revealed one 20 gallon size trash receptacle and one 20 gallon size soiled linen receptacle were stored together in the 1st Floor Emergency Area Exam Room Number 10. These two trash and soiled linen receptacles together exceeded 32 gallons capacity in a 64 square foot area.

3. On 11/13/2018 at 10:30 am, observation revealed one 48 gallon size and two 24 gallon size trash receptacles were stored together in the 1st Floor Cath Lab Area Exam Room Number 1139. These three trash receptacles together exceeded 32 gallons capacity in a 64 square foot area.

These deficient practices were confirmed by Staff Z (Facility Supervisor), Staff Y (Patient Care Manager), Staff CC (Project Manager) & Staff DD (Director of Facilities) at the time of discovery.

Based on interview and observation, the facility failed to provide an emergency electrical generator with a remote stop in accordance with the requirements of NFPA 101 - 2012 edition, Sections 9.1.3.1; NFPA 110 - 2010 edition, Sections 5.6.5.6, 5.6.5.6.1, 7.2.1, 7.2.1.1, & 7.2.1.2. These deficiencies had the potential to affect all patients, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On 11/12/2018 at 2:30 PM, observation revealed in the Power Plant Building that all three emergency generators were not located in a dedicated two hour rated room for a level 1 emergency power supply. All three generators were located in an open mezzanine where the lower level was used for large boilers.

2. On 11/12/2018 at 2:30 PM, observation revealed that the prime movers of the emergency generators were located inside the building and remote manual stop stations were not located outside the generator's room.

These deficient practices were confirmed by Staff BB (Operations Specialist), Staff CC (Project Manager) & Staff DD (Director of Facilities) at the time of discovery.

Based on observation and interview, the facility did not maintain the electrical raceway in accordance with the requirements of NFPA 101 - 2012 edition, Sections 9.1.2 and NFPA 70 - 2011 edition sections 314.28(C). This deficiency had the potential to affect an undetermined number of patients, staff and visitors.

Findings include:

On 11/13/2018 at 10:25 am, observation revealed in the 1st Floor Old Cath Lab Room number 1127 that a florescent light fixture was torn off and all the energized wires were hanging from the ceiling without any cover.

This deficient practice was confirmed by Staff Z (Facility Supervisor), Staff Y (Patient Care Manager), Staff CC (Project Manager) & Staff DD (Director of Facilities) at the time of discovery.

Based on observation and interview, the facility failed to maintain Electrical Systems - Receptacles
in accordance with the requirements of NFPA 99 - 2012 edition, sections 6.3.2.2.6.2 (F), 6.3.2.2.4.2
This deficient practice could affect all of the patients, as well as an undetermined number of staff and visitors.

Findings include:

1. On 11/12/18 at 1:28 PM, observation revealed in the Penthouse at the exit door that the 20 AMP receptacle was discolored demonstrating an arc flash. The condition was confirmed at the time of discovery by concurrent interview with Staff Z (Facility Supervisor) and Staff Y (Patient Care Manager).

Based on observation and staff interview, the facility did not ensure that extension cords were not used as a substitute for fixed wiring of a structure and that extension cords used temporarily were removed immediately upon completion of the purpose for which it was used, per NFPA 99 (2012 edition), 10.2.4 and NFPA 70 (2011 edition), 400.8. This deficient practice could affect all inpatients and an undermined number of staff and visitors.

Findings include:

1. On 11/12/18 at 12:53 PM, observation revealed in the Penthouse that (1) extension cord was used to power the paging system. The condition was confirmed at the time of discovery by concurrent interview with Staff Z (Facility Supervisor) and Staff Y (Patient Care Manager).

2. On 11/12/18 at 2:12 PM, observation revealed on the third floor in the Med Surgery smoke compartment outside of room #3301 that a pencil sharpener was plugged into a power strip. The condition was confirmed at the time of discovery by concurrent interview with Staff Z (Facility Supervisor) and Staff Y (Patient Care Manager).

3. On 11/12/18 at 3:46 PM, observation revealed on the third floor in the Med Surgery smoke compartment outside of room #3200-S that a Otoscope was plugged into a power strip. The condition was confirmed at the time of discovery by concurrent interview with Staff Z (Facility Supervisor) and Staff Y (Patient Care Manager).

4. On 11/12/18 at 1:35 PM, observation revealed in the Penthouse that a communication systems rack was plugged into a power strip. The condition was confirmed at the time of discovery by concurrent interview with Staff Z (Facility Supervisor) and Staff Y (Patient Care Manager).

Based on observation and interview, the facility failed to maintain Gas Equipment - Cylinder and Container Storage in accordance with the requirements of NFPA 99 - 2012 edition, sections 11.3.1, 11.3.2, 11.3.2.3, 11.3.3, 11.3.4, 11.6.5 (NFPA 99). This has the potential to affect an undetermined number of inpatients, staffs and visitors.

Findings include:

1. On 11/12/18 at 2:26 PM, observation revealed on the third floor in the Med Surgical smoke compartment Equipment Storage room 3302C4 that it was being used to store oxygen and was not separated from combustible materials . The condition was confirmed at the time of discovery by concurrent interview with Staff Z (Facility Supervisor) and Staff Y (Patient Care Manager).