HospitalInspections.org

Based on observation, the facility failed to maintainn a safe path of egress. This was evidenced by broken glass found along the walking surface of a stairwell's egress path. This had the potential to impede egress and cause injury to patients and staff. This affected nine of ten floors in the McLeod Tower at Campus A.

NFPA 101 - Life Safety Code, 2012 Edition
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.
7.1.6.4* Slip Resistance. Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel.
7.2.2.3.3.2* Stair treads and landings shall be free of projections or lips that could trip stair users.

Findings:

During a tour of the facility with the Hospital Staff from 4/9/18 through 4/12/18, the facility's means of egress was observed.

Campus A, McLeod Tower:
On 4/11/18, at 8:23 a.m., there was a broken glass bottle of Tabasco that was found along the walking surface in Stairwell #6, between the 2nd and 3rd floors. The Hospital Staff (FM 8) was present when the deficiency was identified.

Based on observation, the facility failed to maintain their emergency lighting. This was evidenced by one battery-powered emergency light in a stairwell that failed to illuminate when tested. This could result in the increased risk of injury during an evacuation. This affected evacuation from three of ten floors of the McLeod Tower at Campus A.

NFPA 101, Life Safety Code, 2012 Edition.
7.9.2.6* Existing battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code.

Findings:

During a facility tour with the Hospital Staff from 4/9/18 through 4/12/18, the battery-powered emergency lights in the stairwells were tested.

Stairwell 6, Campus A:

On 4/11/18, at 8:22 a.m., the battery-powered emergency light between Floors 7 and 8 failed to illuminate when tested by FM 4.

Based on observation, record review, and interview, the facility failed to maintain their exit signs. This was evidenced by the failure to replace an expired photoluminescent exit sign, by the failure of exit signs equipped with battery back-up, and by no records of an annual test of the exit signs equipped with battery back-up. This could result in delayed evacuation during an emergency. This affected one of five suites in the Outpatient Services Building and one of ten floors in the McLeod Tower at Campus A.

NFPA 101, Life Safety Code, 2012 Edition
39.2.10 Marking of Means of Egress. Means of egress shall have signs in accordance with Section 7.10.
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4.
7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance with 7.9.3.1.3.
7.10.9.2 Testing. Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.
7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 11/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
4.6.12.3* Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

Findings:

During a tour of the facility with the Hospital Staff from 4/9/18 through 4/12/18, the exit signs were observed.

Outpatient Services Building, Suite 100:
1. On 4/11/18, at 1:14 p.m., the facility failed to replace an exit sign that was marked "Replace Before 12/2016." The Hospital Staff (FM 12) was present when the deficiency was identified. The exit sign was located above the closet near the Physical Therapy treatment area.


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Campus A, 9th Floor:

2. On 4/10/18, at 2:59 p.m.,there were two exit signs outside the dining room equipped with battery packs for back-up power. The exit signs failed to illuminate when the test button was pushed by FM 4.

3. On 4/10/18, at 3:04 p.m., the exit sign outside Room 920 was equipped with a battery pack for back-up power. The exit sign failed to illuminate when the test button was pushed by FM 4.

4. On 4/10/18, at 3:10 p.m., the exit sign outside Room 924 was equipped with a battery pack for back-up power. The exit sign was missing its test button and the battery's functionality could not be verified.

5. On 4/10/18, at 3:12 p.m., the exit sign outside Room 928 was equipped with a battery pack for back-up power. The exit sign failed to illuminate when the test button was pushed by FM 4.

6. On 4/11/18, at 10:18 a.m., records provided showed that all exit signs were inspected monthly. There were no records of an annual 90-minute test of the exit signs equipped with battery back-up.
During an interview at 10:36 a.m., FM 8 stated that the annual 90-minute test was not conducted on the exit signs with battery back-up.

Based on observation, the facility failed to ensure that alcohol-based hand rub (ABHR) dispensers were installed in a safe manner. This was evidenced by two ABHR dispensers that was installed directly above ignition sources. This affected one of five suites in the Outpatient Services Building. This could result in the increased risk of an electrical fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.2.6 Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1, unless all of the following conditions are met:
(8) Dispensers shall not be installed in the following locations:
(a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source.
(b) To the side of an ignition source within a 1 in. (25mm) horizontal distance from the ignition source.
(c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source.

Findings:

During a facility tour with the Hospital Staff from 4/9/18 through 4/12/18, the ABHR dispensers were observed.

Outpatient Services Building, Suite 105:

1. On 4/11/18, at 1:08 p.m., the ABHR dispenser in Exam Room 3 of the Wound Care Clinic was installed directly above a light switch. Labels indicated that the contents of the dispenser was comprised of 62% ethyl alcohol. FM 11 confirmed the finding.

2. On 4/11/18, at 1:16 p.m., the ABHR dispenser in the Biohazard Room, across from the hyperbaric chamber room, was installed directly above a light switch. Labels indicated that the contents of the dispenser was comprised of 62% ethyl alcohol. FM 11 confirmed the finding.

Based on observation, record review, and interview, the facility failed to maintain their fire alarm system and devices. This was evidenced by no records of testing a battery-powered smoke alarm, by one manual pull station with obstructed access, and by the failure of the main fire alarm control panel (FACP) to emit an audible supervisory alarm. This affected ten of ten floors at Campus A and could result in a delay in responding to a supervisory condition such as closure of the sprinkler system control valves.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.
4.6.12.3* Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or
removed.

NFPA 72, National Fire Alarm Signaling Code, 2010 Edition.
10.2 Puspose. The purpose of the fire alarm and signaling systems shall be primarily to provide notification of alarm, supervisory, and trouble conditions; to alert the occupants; to summon aid; and to control emergency control functions.
10.7.1 Priority alarms, fire alarms, supervisory signals, and trouble signals shall be distinctively and descriptively annunciated.
10.7.3* Audible signals on a control unit, or on multiple control units that are interconnected to form a system, or at a
remote location, shall be permitted to have the same audible characteristics for all alerting functions including, but not limited to, alarm, trouble, and supervisory, provided that the distinction between signals shall be by other appropriate means, such as visible annunciation.
10.7.4* Supervisory signals shall be distinctive in sound from other signals, and their sound shall not be used for any other purpose except as permitted in 10.7.3.
10.14.3.2 Manual fire alarm boxes shall comply with Section 17.14 and 23.8.5.2.1.
14.2.1.1.1 Inspection, testing, and maintenance programs
shall satisfy the requirements of this Code and conform to the equipment manufacturer's published instructions.
17.14.5 Manual fire alarm boxes shall be installed so that they are conspicuous, unobstructed, and accessible.

Findings:

During a facility tour with the Hospital Staff from 4/9/18 to 4/12/18, the fire alarm system and devices were observed.

Campus A, 9th Floor:

1. On 4/10/18, at 2:51 p.m., there was a battery-powered smoke alarm in the public bathroom across from Room 901A. FM 4 and FM10 were asked to provide records of testing the smoke alarm in accordance with the manufacturer's specifications.

On 4/11/18, at 9:55 a.m., FM 8 stated that the smoke alarm was not being tested and would be removed since the bathroom was equipped with a system heat detector.

Campus A, Ground Level:

2. On 4/10/18, at 3:30 p.m., access to the pull station on the loading dock was obstructed by equipment like tables, chairs, and other miscellaneous items. FM 8 confirmed the finding.

Campus A, Private Branch Exchange (PBX) Office:

3. On 4/11/18, at 8:54 a.m., the tamper switches on the supervised sprinkler control valves were tested and the main FACP at the PBX office was observed. Upon closure of the valves, a visual supervisory signal was activated but there was no audible signal emitted.
During a concurrent interview, VEN 15 confirmed the finding and stated that some wiring in the panel had to be re-soldered to fix the audible on the panel.

Based on observation, the facility failed to maintain their automatic sprinkler system as evidenced by sprinklers found with foreign materials. This could affect the operation of the sprinkler system, causing delay in extinguishing a fire and resulting in injury to patients and staff. This affected two of eleven floors at Campus B.

NFPA 101 - Life Safety Code, 2012 Edition
19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25 - Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition
5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).

During a tour of the facility with the Hospital Staff from 4/9/18 through 4/12/18, the sprinkler system was observed.

Campus B, 2nd Floor:
1. On 4/9/18, at 4:07 p.m., the pendent type sprinkler, located near an air vent in the Operating Room's Male Locker Room (Door Frame #02-S2SV), had its fusible link, its arm, and its deflector covered with dust/debri. The Hospital Staff (FM 6 and FM 7) were present when the deficiency was identified.

Campus B, 3rd Floor:
2. On 4/10/18, at 8:40 a.m., the pendent type sprinkler, located near an ice machine in the Cafe's Pot Wash Room (Door Frame #03-701B), had its fusible link covered with dust/debri. The Hospital Staff (FM 6) was present when the deficiency was identified.

NFPA 101, Life Safety Code, 2012 Edition.
4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

Based on observation, record review, and interview, the facility failed to maintain their electrical appliances in accordance with manufacturer's specifications. This was evidenced by the failure to clean the exhaust vent of one clothes dryer and this could result in the increased risk of a fire. This affected one of ten floors in the McLeod Tower at Campus A.

Findings:

During a facility tour with the Hospital Staff from 4/9/18 through 4/12/18, appliances connected to the building utilities were observed.

Campus A, 9th floor:

On 4/10/18, at 3:06 p.m., there was an electrical dryer observed in the Occupational Therapy (OT) room. The dryer was equipped with a vent that went up to the roof. A log indicated that the washer and dryer in the OT room were used periodically by staff and were last used on 4/8/18.
During a concurrent inerview, FM 4 and FM 10 stated that they were unaware that the equipment was being used and were not periodically maintaining the vent on the roof.

At 3:16 p.m., the vent screen on the roof had a thick accumulation of lint which was immediately removed by FM 10.

On 4/11/18, at 4:35 p.m., the manufacturer's specifications for the dryer indicated that the interior of the dryer and exhaust vent should be cleaned "periodically" to reduce the risk of fire.

Based on observation and interview, the facility failed to ensure that portable space heaters used in staff areas had heating elements in accordance with the Code. This was evidenced by no specifications provided by one portable space heater observed in the Private Branch Exchange (PBX) office. This affected one of ten floors of the McLeod Tower at Campus A. This could result in the increased risk of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.7.8 Portable Space-Heating Devices. Portable spaceheating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:
(1) Such devices are used only in nonsleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212°F (100°C).

Findings:

During a facility tour with the Hospital Staff from 4/9/18 through 4/12/18, the facility was observed for portable space heaters. The PBX office housed the main fire alarm panel and annunciator panels for the generators and other essential building systems.

Campus A, 3rd Floor:

On 4/11/18, at 8:52 a.m., there was a portable space heater in the PBX office. The space heater was plugged in but not in use during observation. The specifications of the heating elements of the heater were not provided.

During an interview at 9:06 a.m., FM 8 stated that the facility prohibits the use of portable space heaters at all locations. He said that central heating in the PBX office depends on a heating coil in the adjacent pharmacy but facilities has had no access to the pharmacy to do necessary repairs and staff may have brought in the space heater when it was too cold.

Based on record review and interview, the facility failed to maintain their medical gas systems. This was evidenced by no records of repairing all the discrepancies identified during an annual inspection. This could result in the increased risk of a hazardous condition and injuries. This affected one of ten floors of the McLeod Tower at Campus A.

NFPA 99, Health Care Facilities Code, 2012 Edition.
5.1.14.2.3.1 General. The elements in 5.1.14.2.2.2 through 5.1.15 shall be inspected or tested as part of the maintenance program as follows:
(11)*Station outlets/inlets, as follows:
(a) Flow
(b) Labeling
(c) Latching/delatching
(d) Leaks

5.1.14.2.3.2 Manufactured Assemblies Employing Flexible Connection(s) Between the User Terminal and the Piping System.
(E) Leaks, if any, shall be repaired (if permitted), or the components replaced (if required), and the equipment retested prior to placing the equipment back into service.

Findings:

During record review with the Hospital Staff from 4/9/18 through 4/12/18, the medical gas system maintenance records were reviewed.

Campus A, 4th Floor:

On 4/11/18, at 9:15 a.m., records showed that the system was inspected on 5/15/17. There were no records of repairing all deficiencies noted on the report. Deficiencies noted on the report include leakage and damage to hoses and connections of the medical gas manufactured assemblies in Operating Rooms (ORs) 2, 3, 8, 9, and 10. There were also medical gas outlet discrepancies noted that were not repaired including leaks at the vacuum system outlets at Pre-Operative (Pre-Op) Beds 2 and 3.

During an interview at 9:35 a.m., FM 8 confirmed the finding and stated that the isolation valves for those areas were closed due to the Surgery department being closed.

At 10:05 a.m., zone valves for all areas in the surgical department were observed to be open and the medical gas system was pressurized (except for Nitrogen).
During a concurrent interview, FM 3 stated that the facility planned to keep OR 8 fully operational as part of their emergency plan.

Based on record review and interview, the facility failed to maintain their uninterruptible power supply (UPS) systems. This was evidenced by incomplete records of load testing the systems, by a delay in repairing a battery that failed during an annual inspection, by no records of monthly inspections of the systems, and by no records of maintaining the systems in accordance with manufacturer recommendations. This affected four of four catheterization laboratories (cath labs) at Campus B. This could result in the increased risk of failure of the UPS systems and interruption of procedures during power surges or similar events.

NFPA 101, Life Safety Code, 2012 Edition.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1.4 Stored Electrical Energy Systems. Stored electrical energy systems shall be installed, tested, and maintained in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems, 2010 Edition.
3.3.5.1 Stored Emergency Power Supply System (SEPSS). A system consisting of a UPS, or a motor generator, powered by a stored electrical energy source, together with a transfer switch designed to monitor preferred and alternate load power source and provide desired switching of the load, and all necessary control equipment to make the system functional.
3.3.8.2* Uninterruptible Power Supply (UPS). A system consisting of a stored energy source, designed to continuously provide a clean, conditioned sinusoidal wave of power under normal conditions and for a finite period of time upon
loss of the primary power source.
8.3.3.1 Areproducible record of inspection, tests, and repairs shall be maintained on the premises (see Table A.8.3.2).
8.3.3.2 The record shall include the following:
(1) Completion of a log
(2) Notification of any unsatisfactory condition and the corrective actions taken, including parts replaced
(3) Identification of the servicing personnel
(4) Documentation of a completed test of the SEPSS, according to 8.4.1, immediately following any repair or battery replacement
8.4 Operational Inspection and Testing.
8.4.1* Level 1 equipment shall be inspected monthly and tested in accordance with the manufacturer's recommendations.
8.4.2* Inspection of the equipment shall include the following:
(1) The battery and associated charger/control equipment shall be checked to verify that they are in a clean and satisfactory condition and that no exceptional environmental or other conditions exist that could damage or affect performance.
(2) Battery electrolyte levels shall be checked, where applicable, and refilled as necessary.
(3) Terminals and intercell connectors shall be cleaned and regreased, if necessary, and cell tops shall be cleaned.
(4) Individual cell voltages shall be checked and recorded where practical.
(5) The specific gravity of pilot cells shall be checked and recorded, where applicable.
(6) The conditions of the plates and sediment of free electrolyte, LA batteries in transparent containers shall be noted.
(7) All indicator lamps, meters, and controls shall be checked to verify that they are operating correctly.
(8) The load value shall be checked to ensure that it is within the equipment rating.
8.4.3 Load Testing.
8.4.3.1 A load test shall be performed as required by 8.4.1. The output voltage, battery voltage, and duration of the test shall be recorded at the beginning and at the end of the test for each battery set.

Findings:

During record review with the Hospital Staff from 4/9/18 through 4/12/18, the records of inspections and tests of the cath lab UPS systems were requested. UPS 21 was a 40 kW system serving Cath Labs 2 and 4. UPS 22 was a 40 kW system serving Cath Labs 1 and 3.

Campus B, 2nd Floor:

1. On 4/11/18, at 2:50 p.m., records indicated that annual load tests were conducted on UPS 21 and UPS 22 on 9/28/17. The duration of the load tests were not recorded as required by NFPA 111.

2. On 4/11/18, at 2:51 p.m., records indicated that Battery 21 of UPS 22 failed testing with a reading of below 10% of its required voltage. The battery was not replaced until the following semi-annual inspection on 2/6/18.

3. On 4/12/18, at 8:55 a.m., the manufacturer recommendations for maintenance of the UPS systems were provided. The manufacturer indicated that these unit batteries did not require addition of water or electrolyte but charging, voltage, temperature, perforance and connection resistance "must be monitored periodically." The manufacturer outlined procedures for recommended quarterly and semi-annual inspections. The unit manuals also indicated that cooling fans were to be replaced once every three years, capacitors once every five years, and fuses once every seven years. The facility failed to provide records of monthly inspections in accordance with NFPA 111 and failed to provide records of maintenance in accordance with manufacturer recommendations.

During an interview, BIO 14 confirmed that the facility did not perform monthly or quarterly inspections of the UPS system.

Based on observation and interview, the facility failed to maintain the electrical system as evidenced by the use of non compliant extension cords and power strips. This could result in the ignition of an electrical fire. This affected one of ten floors in the McLeod Tower at Campus A and one of eleven floors at Campus B.

NFPA 101, Life Safety Code, 2012 edition
19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 edition
400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage
590.3 Time Constraints.
(A) During the Period of Construction. Temporary electric power and lighting installations shall be permitted during the period of construction, remodeling, maintenance, repair, or demolition of buildings, structures, equipment, or similar activities.
(B) 90 Days. Temporary electric power and lighting installations shall be permitted for a period not to exceed 90 days for holiday decorative lighting and similar purposes.
(D) Removal. Temporary wiring shall be removed immediately upon completion of construction or purpose for which the wiring was installed.

NFPA 99, Health Care Facilities Code, 2012 Edition.
10.2.3.6 Multiple Outlet Connection. Two or more power receptacles supplied by a flexible cord shall be permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, pedestal-, or cartmounted, provided that all of the following conditions are met:
(1) The receptacles are permanently attached to the equipment assembly.
(2)*The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets.
(3) The ampacity of the flexible cord is in accordance with NFPA 70, National Electrical Code.
(4)*The electrical and mechanical integrity of the assembly is regularly verified and documented.
(5)*Means are employed to ensure that additional devices or nonmedical equipment cannot be connected to the multiple outlet extension cord after leakage currents have been verified as safe.
10.2.4 Adapters and Extension Cords.
10.2.4.1 Three-prong to two-prong adapters shall not be permitted.
10.2.4.2 Adapters and extension cords meeting the requirements of 10.2.4.2.1 through 10.2.4.2.3 shall be permitted.
10.2.4.2.1 All adapters shall be listed for the purpose.
10.2.4.2.2 Attachment plugs and fittings shall be listed for the purpose.
10.2.4.2.3 The cabling shall comply with 10.2.3.

Findings

During a tour of the facility with the Hospital Staff from 4/9/18 through 4/12/18, the facility electrical equipment was observed.

Campus A, McLeod Tower, 2nd Floor:
1. On 4/10/18, at 2:54 p.m., there was office equipment plugged into a power strip that was then plugged into an extension cord, instead of directly into a wall outlet. The Hospital Staff (FM 8) was present when the deficiency was identified in the Psychiatrist Office by the Behavioral Health Unit.










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Campus B, 2nd Floor:

2. On 4/10/18, at 8:26 a.m., there were equipment battery chargers plugged into a three-plug extension cord in the north core of Surgical Services.
During a concurrent interview, FM 9 stated that this type of extension cord was not approved for use at the facility.

Based on observation, the facility failed to properly store their oxygen cylinders as evidenced by a portable oxygen cylinder that was not properly secured. This could cause harm to patients or staff in the event that the cylinder fell on something or someone and/or the high pressure valve was damaged and caused the cylinder to move about in an uncontrolled manner. This affected one of eleven floors in Campus B.

NFPA 99 - Health Care Facilities, 2012 Edition
11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures:
(1) Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device.
(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During a tour of the facility with the Hospital Staff from 4/9/18 through 4/12/18, oxygen cylinders were observed.

Campus B, 1st Floor:
1. On 4/10/18, at 11:21 a.m., the oxygen cylinder, located in the Lobby's wheelchair storage area, was found standing upright and unsecured. The oxygen cylinder was an E-size, containing approximately 24 cubic feet of volume. The Hospital Staff (FM 6) was present when the deficiency was identified.

Based on observation, the facility failed to maintain their oxygen cylinder storage areas. This was evidenced by the absence of required precautionary signs at two oxygen storage locations and by the failure to segregate empty and full cylinders. This could result in a delay in identifying sources of ignition sources and could result in the increased risk of confusion if a full cylinder is needed in a rapid manner. This affected two of eleven floors at Campus B.

NFPA 99, Health Care Facilities Code, 2012 Edition.
11.3.4 Signs.
11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure.
11.3.4.2 The sign shall include the following wording as a minimum:
CAUTION:
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING
11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders.
11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner.

Findings:

During a tour of the facility with the Hospital Staff from 4/9/18 through 4/12/18, the oxygen cylinders storage areas were observed.

Campus B, 6th Floor:

1. On 4/9/18, at 2:10 p.m., there were oxygen cylinders stored in the Equipment Room 06-620-A but no precautionary signage on the door to indicate that oxidizing gases were stored within. Hospital Staff (FM 2) confirmed the finding.

2. On 4/9/18, at 2:20 p.m., there was one empty oxygen C-cylinder among five full oxygen C-cylinders in the oxygen cabinet designated for "FULL" cylinders. The empty oxygen cylinder was in the first row of the cabinet, was not marked, and contents of the cylinders were confirmed using their gauges. FM 2 confirmed the finding.

Campus B, 5th Floor:

3. On 4/9/18, at 3:00 p.m., there were oxygen cylinders stored in Equipment Room 06-620-A but no precautionary signage on the door to indicate that oxidizing gases were stored within. Hospital Staff (FM 2) confirmed the finding.