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Based on documentation review and interview, it was determined the facility failed to address the insufficient supply of emergency power in the Emergency Response Plan for the facility.

Findings include:

Review of Emergency preparedness documentation on January 17, 2018, at 10:12 AM, revealed the facility failed to address the lack of emergency power, or an alternative strategy, for the hospital air conditioning system, in the Emergency Response Plan.

Exit interview with facility administrator and maintenance representative #1 on January 17, 2018, between 12:00 PM and 12:15 PM, confirmed the facility failed to address the insufficient supply of emergency power in the Emergency Response Plan.

Based on observation and interview, it was determined the facility failed to maintain one alcohol-based hand rub station, affecting one of seven floors.

Findings include:

1. Observation on January 17, 2018, at 11:14 AM, revealed a trash can was placed beneath the ABHR within first floor SPU.

Exit interview with facility administrator and maintenance representative #1 on January 17, 2018, between 12:00 PM and 12:15 PM, confirmed the ABHR deficiency.

Based on observation and interview, it was determined the facility failed to maintain exit stair towers in one instance, affecting one of three exit stairs within the facility.

Findings include:

1. Observation on January 17, 2018, at 11:09 AM, revealed the 4th floor, Center stair tower had an unsealed penetration located above the door in the elevator lobby.

Exit interview with facility administrator and maintenance representative #1 on January 17, 2018, between 12:00 PM and 12:15 PM, confirmed the penetration.

Based on observation and interview, it was determined the facility failed to maintain exit access in multiple locations, affecting one of seven floors.

Findings include:

1. Observation on January 17, 2018, between 10:22 AM and 10:44 AM, revealed the basement-level, exit access corridor system contained stationary items in multiple locations.

Exit interview with facility administrator and maintenance representative #1 on January 17, 2018, between 12:00 PM and 12:15 PM, confirmed the exit access deficiency.

Based on documentation review and interview, it was determined the facility failed to maintain emergency lighting in multiple locations.

Findings include:

1. Observation on January 17, 2018, at 9:44 AM, revealed the facility lacked required, annual 90 minute testing data for all battery-operated lighting fixtures.

Exit interview with facility administrator and maintenance representative #1 on January 17, 2018, between 12:00 PM and 12:15 PM, confirmed the emergency lighting deficiency.

Based on observation and interview, it was determined the facility failed to install and maintain exit signage in one location, affecting one of seven floors.

Findings include:

1. Observation on January 17, 2018, at 10:55 AM, revealed the exit sign located within the Conference Room, located adjacent to the first floor Gift Shop, lacked illumination.

Exit interview with facility administrator and maintenance representative #1 on January 17, 2018, between 12:00 PM and 12:15 PM, confirmed the exit sign lacked illumination.

Based on observation and interview, it was determined the facility failed to maintain vertical openings on seven of seven floors.

Findings include:

1. Observation on January 17, 2018, between 10:57 AM and 11:45 AM, revealed dumb waiter doors lacked fire resistive labeling.

Exit interview with facility administrator and maintenance representative #1 on January 17, 2018, between 12:00 PM and 12:15 PM, confirmed the vertical opening deficiency.

Based on observation and interview, it was determined the facility failed to maintain one hazardous area enclosure, affecting one of seven floors.

Findings include:

1. Observation on January 17, 2018, at 10:12 AM, revealed the basement-level, Central Distribution Center door was held open by unapproved means.

Exit interview with facility administrator and maintenance representative #1 on January 17, 2018, between 12:00 PM and 12:15 PM, confirmed the hazardous area enclosure deficiency.

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers in one instance, affecting one of approximately twenty fire extinguishers within the component level.

Findings include:

1. Observation on January 17, 2018, at 9:45 AM, revealed the fire extinguisher located in the 8th floor Penthouse was unsecured on the floor.

Exit interview with facility administrator and maintenance representative #1 on January 17, 2018, between 12:00 PM and 12:15 PM, confirmed the unsecured fire extinguisher.

Based on observation and interview, it was determined the facility failed to maintain five corridor openings, affecting two of seven floors.

Findings include:

1. Observation on January 17, 2018, between 10:17 AM and 11:50 AM, revealed the following:

a. 10:17 AM, distance between the basement-level Clean Linen Room doors exceeded 1/8 inch;
b. 11:46 AM, Patient Room 307 door lacked smoke-tight integrity;
c. 11:47 AM, Patient Room 315 door lacked smoke-tight integrity;
d. 11:48 AM, Patient Room 320 door lacked smoke-tight integrity;
e. 11:50 AM, Patient Room 322 door lacked smoke-tight integrity.

Exit interview with facility administrator and maintenance representative #1 on January 17, 2018, between 12:00 PM and 12:15 PM, confirmed the corridor opening deficiencies.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring and equipment in one instance, affecting one of seven floors within the facility.

Findings include:

1. Observation on January 17, 2018, at 10:20 AM, revealed the 6th floor, Staff Breakroom #652 had a coffee pot and microwave oven plugged into a surge protector.

Exit interview with facility administrator and maintenance representative #1 on January 17, 2018, between 12:00 PM and 12:15 PM, confirmed the unauthorized use of a surge protector.

Based on documentation review and interview, it was determined the facility failed to maintain the piped-in medical gas system, affecting seven of seven floors.

Findings include:

1. Observation on January 17, 2018, at 9:55 AM, revealed the facility lacked a current medical gas inspection report.

Exit interview with facility administrator and maintenance representative #1 on January 17, 2018, between 12:00 PM and 12:15 PM, confirmed the facility lacked a current medical gas inspection report.