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Based on observation and interview the facility failed to ensure that aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1. This deficient practice could affect all occupants of the 2nd, 4th, 5th and 6th floors of the facility.

On 4-26-18 between 9:30 am & 4:30 pm observed nurse charting racks in exit corridors in the following locations:

Building # 1 - Butterworth Campus
6th Floor-North chart racks near rooms 6031, 6032 and 6024.
5th Floor-North chart racks near rooms 5007, 5015, 5016 and 5022.
4th Floor-North chart rack near room 4025.
2nd Floor-West chart rack across from room 2579.

These deficiencies were confirmed by the Safety Specialist at time of discovery.

Based on observation and interview the facility failed to provide Gas and Vacuum systems in accordance with NFPA 99. This deficient practice could affect all occupants of the facility by contributing to the spread of fire in the gas storage area due to unapproved storage within the space:

On 4/24/18 at approximately 11:30 am the following deficiency was observed:

Building # 1 Med-gas storage room was observed to have approximately 20 plastic medical equipment carts on wheels and plastic covers to be stored in the med-gas room.


This deficiency was confirmed by the Safety Specialist at time of discovery.