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Based on observation, testing, and interview, the provider failed to maintain proper separation of a hazardous area. The north exit corridor vestibule was used for storage of large bins of soiled linens and trash. The two corridor doors were not rated and had no latching hardware. Findings include:

1. Observation at 9:30 a.m. on 6/14/11 revealed the north exit corridor vestibule was used for storage of three in-use large rolling soiled linen bins (approximately 50 gallons each), two in-use large rolling trash bins (approximately 50 gallons each), and two large stacks of plastic totes. Further observation and testing revealed the two corridor doors were not rated and had no latching hardware. Interview with the director of plant operations (DPO) at the time of the observation confirmed that condition. He stated an area had not been designed for soiled linen and trash storage when the building was remodeled about two years ago. The DPO revealed staff now used that area for storage of soiled linen and trash bins.

Based on observation and interview, the provider failed to maintain the width of corridors (clear and unobstructed) that served as exit access. The north exit vestibule had three large soiled linen bins, two large trash bins, and two large stacks of red totes. Findings include:

1. Observation at 9:30 a.m. on 6/14/11 revealed the north exit corridor vestibule was used for storage of three in-use large rolling soiled linen bins (approximately 50 gallons each), two in-use large rolling trash bins (approximately 50 gallons each), and two large stacks of plastic totes. Interview with the director of plant operations (DPO) at the time of the observation confirmed that condition. He stated an area had not been designed for soiled linen and trash storage when the building was remodeled about two years ago. The DPO revealed staff now used that area for storage of soiled linen and trash bins. The DPO further revealed he was aware corridors could not be restricted and exit access could not be obstructed.

Based on observation, testing, and interview, the provider failed to maintain proper separation of a newly created hazardous area. The north exit corridor vestibule was used for storage of large rolling bins of soiled linens and trash. The two corridor doors were not rated and had no latching hardware. Findings include:

1. Refer to K029 and K039.

Based on observation and interview, the provider failed to post precautionary signs were oxygen was stored. Findings include:

1. Observation at 10:15 a.m. on 6/15/11 revealed the outside oxygen storage area with four oxygen Dewars did not have precautionary signage for the area or location. Continued observation at 10:20 a.m. on that same day revealed three E sized oxygen cylinders were stored at the west entrance to the receiving area for the clean storage room. Interview with the director of plant operations at the time of the above observations confirmed those findings. He stated he was aware oxygen locations and storage areas must have precautionary signage. The DPO said he had ordered signs when the outside storage area was moved but had not installed them on the chain link fence surrounding the outside location.

The provider must comply with National Fire Protection Association (NFPA) 70 article 305-Temporary Wiring. (See attachment.)

Based on observation and interview, the provider failed to install permanent wiring for medical use equipment and operating rooms. Power strips and/or extension cords were found in-use in place of permanent wiring in the following areas/rooms:
- The post operative acute care unit (PACU).
- Five of ten operating rooms (OR) (1, 2, 3, 5, and 7).
Findings include:

1. Observation from 11:00 a.m. to 2:30 p.m. on 6/15/11 revealed power strips and/or extension cords in use in place of permanent wiring in the following areas/rooms:
- An extension cord was found attached to the electrical cord for the ultrasound machine in PACU.
- An extension cord was found attached to the electrical cord of an OR table in OR 3. The connection between the extension cord and electrical cord of the OR table had been taped together.
- An extension cord was found attached to an unapproved power strip in OR 5. The connection between the extension cord and the power strip had been taped together.
- An extension cord was found attached to a Bovie cart in OR 2.
- Six unapproved Ace power strips were in-use in ORs 1, 2, 3, 5, and 7.

Interview on 6/15/11 at 2:30 p.m. with the OR nurse manager revealed:
*Anesthesia had brought in the non-hospital grade power strips.
*He was not aware extension cords were not to be used.
*He was not aware that longer permanent cords could be attached to equipment by biomedical.
*He was only responsible for the OR equipment, and anesthesia was responsible for their carts.
*The extension cords had been taped to ensure the connection did not come apart.
*He agreed the use of tape to ensure the cords stayed together was not a good practice.

Continued interview at 3:45 p.m. on that same day with the plant operations manager revealed he had just done a walk through of the facility last month and removed extension cords and power strips. He stated he was aware only hospital grade power strips were approved and Ace hardware power strips were not approved. He was also aware extension cords could not be used for medical equipment or for extensions of permanent wiring in ORs.

Based on policy review and interview, the provider was unaware a policy must be in place for notification of authorities and implementation of a fire watch when the fire sprinkler system was out of service for more than 4 hours in a 24 hour period. Findings include:

1. Policy review revealed the provider's administrative and emergency policies did not include a policy for notification of authorities and implementation of a fire watch when the fire sprinkler system was out of service for more than 4 hours in a 24 hour. Interview on 6/15/11 at 3:30 p.m. with the director of plant operations revealed he had contacted the Department of Health when they had remodeled the building but was not aware of the 4 hour notification requirement. Interview at 4:30 p.m. on that same day with the administrator revealed the policies would be revised for compliance with the requirement.

Based on policy review and interview, the provider was unaware a policy must be in place for notification of authorities and implementation of a fire watch when the fire alarm system was out of service for more than 4 hours in a 24 hour period. Findings include:

1. Policy review revealed the provider's administrative and emergency policies did not include a policy for notification of authorities and implementation of a fire watch when the fire alarm system was out of service for more than 4 hours in a 24 hour. Interview on 6/15/11 at 3:30 p.m. with the director of plant operations revealed he had contacted the Department of Health when they had remodeled the building but was not aware of the 4 hour notification requirement. Interview at 4:30 p.m. on that same day with the administrator revealed the policies would be revised for compliance with the requirement.