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Based on observations, interviews, record and plan review, the facility failed to provide travel distance to exits not to exceed 100ft., for the operating suite (S10) which has two operating rooms (OR) #4 and #5. 19.2.6.2.1 The facility census was 212.

Findings included:

1. Observation and plan review on 12/14/11 at 9:00 AM showed the travel distance from OR#4 to the northeast exit door to be 111 feet, and the distance from OR#5 to the northwest exit door to be 111 feet. The excess distance to the exit doors is 11 feet for either OR suite.

2. During an interview and record review on 12/14/11 at 9:30 AM Staff X stated that the two operating rooms are larger than the other six operating rooms in the suite and both rooms receive the heaviest use because of their size and proximity to the sterile corridor.

Based on observation and interview, the facility failed to provide secure storage of medical and other compressed gases in accordance with NFPA 99, (5.1.3.3.2(7)) with racks, chains or other fastenings to individually secure all cylinders to prevent them from falling or inadvertently being tipped over during change-outs, potentially affecting staff, visitors and the facility census of 212 inpatients.

Findings included:

1. Observation on 12/12/11 at 2:25 PM showed two small (six inches wide by 19 inches long) cylinders of nitrogen and a small cylinder of acetylene lying on the floor of the maintenance tool cage. The valve was not protected by a safety cap or collar and no racks or carts were available to secure them to.

2. Observation on 12/13/11 at 11:18 AM showed eight "H" size cylinders oxygen grouped together with a common chain against the wall in a room used for the storage of Respiratory Therapy products. There was no second chain or safety mechanism in place to individually restrain the cylinders and prevent one cylinder from being tipped over and starting a domino-effect chain reaction.

3. Observation on 12/13/11 at 11:25 AM showed a free standing cylinder of compressed gas (carbon dioxide) in the dry food storage area. The cylinder was not secured in a safe manner and lacked the protective collar to prevent the valve from being broken off in case the cylinder was accidentally tipped over.

4. During an interview on 12/13/11 at 11:25AM, Staff X, Senior Director of Corporate Services stated that he will get in touch with the building's Safety Officer to get some collars, chains and racks to store the lose oxygen and acetylene cylinders all around the hospital.

NFPA 101 19.2.5.7
Suites of rooms, other than patient sleeping rooms, shall not exceed 10,000 square feet.

Based on observations, plan review, the facility failed to ensure that the size of operating suite (S10), which contains eight individual operating rooms and one procedure room, is less than 10,000 square feet. The facility census was 212.

Findings included:

1. Observation and plan review on 12/14/11 at 9:00 AM showed a suite containing eight operating rooms and one procedure room measured a total of 13,325 square feet, exceeding the size limitations of the suite by 3,325 square feet.

Based on observations, interviews, record and plan review, the facility failed to provide travel distance to exits not to exceed 100ft., for the operating suite (S10) which has two operating rooms (OR) #4 and #5. 19.2.6.2.1 The facility census was 212.

Findings included:

1. Observation and plan review on 12/14/11 at 9:00 AM showed the travel distance from OR#4 to the northeast exit door to be 111 feet, and the distance from OR#5 to the northwest exit door to be 111 feet. The excess distance to the exit doors is 11 feet for either OR suite.

2. During an interview and record review on 12/14/11 at 9:30 AM Staff X stated that the two operating rooms are larger than the other six operating rooms in the suite and both rooms receive the heaviest use because of their size and proximity to the sterile corridor.

Based on observation and interview, the facility failed to provide secure storage of medical and other compressed gases in accordance with NFPA 99, (5.1.3.3.2(7)) with racks, chains or other fastenings to individually secure all cylinders to prevent them from falling or inadvertently being tipped over during change-outs, potentially affecting staff, visitors and the facility census of 212 inpatients.

Findings included:

1. Observation on 12/12/11 at 2:25 PM showed two small (six inches wide by 19 inches long) cylinders of nitrogen and a small cylinder of acetylene lying on the floor of the maintenance tool cage. The valve was not protected by a safety cap or collar and no racks or carts were available to secure them to.

2. Observation on 12/13/11 at 11:18 AM showed eight "H" size cylinders oxygen grouped together with a common chain against the wall in a room used for the storage of Respiratory Therapy products. There was no second chain or safety mechanism in place to individually restrain the cylinders and prevent one cylinder from being tipped over and starting a domino-effect chain reaction.

3. Observation on 12/13/11 at 11:25 AM showed a free standing cylinder of compressed gas (carbon dioxide) in the dry food storage area. The cylinder was not secured in a safe manner and lacked the protective collar to prevent the valve from being broken off in case the cylinder was accidentally tipped over.

4. During an interview on 12/13/11 at 11:25AM, Staff X, Senior Director of Corporate Services stated that he will get in touch with the building's Safety Officer to get some collars, chains and racks to store the lose oxygen and acetylene cylinders all around the hospital.

NFPA 101 19.2.5.7
Suites of rooms, other than patient sleeping rooms, shall not exceed 10,000 square feet.

Based on observations, plan review, the facility failed to ensure that the size of operating suite (S10), which contains eight individual operating rooms and one procedure room, is less than 10,000 square feet. The facility census was 212.

Findings included:

1. Observation and plan review on 12/14/11 at 9:00 AM showed a suite containing eight operating rooms and one procedure room measured a total of 13,325 square feet, exceeding the size limitations of the suite by 3,325 square feet.