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Marion General Hospital (MGH) was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b) Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies.

The facilities surveyed are MGH Main Building (Building 01), MGH Surgery Center (Building 10), MGH Sleep Lab (Building 09), and MGH Medical Oncology (Building 07).

MGH Building (Building 01), is a five story building fully sprinkled with a partial basement determined to be type I (332) construction with a monitored fire alarm system with smoke detection in the corridors, areas open to the corridors and all patient rooms. Building 01 provides overnight care. The hospital has capacity of 99 and had a census of 80 at the time of this survey.

MGH Medical Oncology, is in a one story building fully sprinkled determined to be Type V (000) construction with pull stations to activate the alarm.

MGH Sleep Lab (Building 09), is in a one story building fully sprinkled determined to be type V (111) construction with a monitored fire alarm system with smoke detection in the corridors, areas open to the corridors.

MGH Surgery Center (Building 10), was located on the third floor of a five story building fully sprinkled determined to be type I (332) construction with a monitored fire alarm system with smoke detection in the corridors, areas open to the corridors and all patient suites.

Building 01:

Based on record review, observation, and interview, the facility failed to ensure 1 of 2 fire door sets that separated the lobby gift shop area from the second floor of the hospital self-closed and latched into the frame (see tag K131), the facility failed to ensure 2 of 2 ER corridor means of egresses were continuously maintained free of obstructions and did not reduce the corridor width by 60 inches (see tag K211), the facility failed to ensure the means of egress through 1 of 1 delayed egress locks on the third floor was readily accessible for all patients, staff, and visitors see tag K222), the facility failed to ensure 1 of 1 stairway enclosure doors in PACU were in accordance with 7.2. (see tag K225), the facility failed to ensure the failure of any single lighting fixture outside of 1 of 2 imaging emergency exits would not leave the area an illumination level of less than 0.2 foot candle (see tag K281), the facility failed to ensure the corridor door to 2 of 5 hazardous storage rooms in ER and 1 of 10 hazardous storage rooms on floor two was provided with a self-closing device which would cause the door to automatically close and latch into the door frame (see tag K321), the facility failed to ensure complete automatic sprinkler system was provided for 1 of 1 third floor housekeeping mop rooms in accordance with NFPA 13-2010 (see tag K351), the facility failed to ensure only one type of sprinkler head i.e. quick response or standard sprinklers were installed in 1 of 1 office lobbies and 1 of 4 birthing center storage rooms (see tag K351), during a tour of the facility with the Maintenance Supervisor on 08/15/18 between 1:00 p.m. and 4:15 p.m. and on 08/16/18 between 10:20 a.m. and 12:00 p.m., the following was observed:
a) All sprinkler heads under the outside main entrance canopy was covered in a green substance.
b) Throughout the building there were sprinkler head lightly and heavily covered in dust. The location of the dirty sprinkler heads were: ER entrance, ER lobby, Dining room, Dish room, throughout the corridors of all floors, and the rooms in the family birthing center.
Based on interview at the time of observations, the Maintenance Supervisor did agree the sprinkler heads under the canopy were green and that there were sprinkler heads covered with dirt throughout the building. The Maintenance Supervisor had maintenance workers clean the sprinkler heads as they were discovered (see tag K353), the facility failed to provide written documentation or other evidence that approximately 26 of 26 dry pendent sprinkler heads were tested or replaced every 10 years (see tag K353), the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 8 of 17 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier (see tag K372) the facility failed to ensure 1 of 2 sets of smoke barrier doors in the ER were self-closing or automatic-closing (see tag K374), the facility failure to ensure 1 of 1 approved portable space heaters were not used in the facility (see tag K781), the facility failed to ensure 5 of 5 flexible cords were not used as a substitute for fixed wiring to provide power equipment with a high current draw or over loaded (see tag A920), the facility failed to ensure 1 of 1 flexible cords were installed properly and used in a safe manor (see tag A920).

Building 07:

Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm system in accordance with 4.5.6. LSC 4.5.6 any fire protection system, building service equipment, feature of protection, or safe-guard provided to achieve the goals of this Code shall be designed, installed, and approved in accordance with applicable NFPA standards (see tag K300), the facility failed to ensure 1 of 1 Pharmacy Sink was provided with a ground fault circuit interrupter (GFCI) protection against electric shock (see tag K500).

Building 09:

Based on observation and interview, the facility failed to ensure 1 of 1 sprinkler system in accordance with 4.5.6. LSC 4.5.6 any fire protection system, building service equipment, feature of protection, or safe-guard provided to achieve the goals of this Code shall be designed, installed, and approved in accordance with applicable NFPA standards (see tag K 353), the facility failed to ensure 1 of 1 sprinkler system in accordance with 4.5.6. LSC 4.5.6 any fire protection system, building service equipment, feature of protection, or safe-guard provided to achieve the goals of this Code shall be designed, installed, and approved in accordance with applicable NFPA standards (see tag K 353), the facility failed to ensure 1 of 1 Testing room 4 was provided with a ground fault circuit interrupter (GFCI) protection against electric shock (see tag K912).

Building 10:

Based on observation and interview, the facility failed to ensure doors in 1 of 1 PACU fire barrier wall were eqiopped with positive latches (see tag K131), the facility failed to maintain 2 of 6 corridors from obstructions per 21.2.1 LSC 21.2.1 states that every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7 (see tag K211), the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 21.3.4.1 (see tag K341), the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 1 of 6 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier (see tag K372), the facility failed to ensure 2 of 6 sets of smoke barrier doors would self-close. This deficient practice could affect staff all occupants in the suite (see tag K374).

Building 01:

Based on record review, observation, and interview, the facility failed to ensure 1 of 2 fire door sets that separated the lobby gift shop area from the second floor of the hospital self-closed and latched into the frame. LSC 8.3.3.3 states fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8. This deficient practice could affect up to 20 patients and visitors that would use the main entrance and 10 patients on the second floor, the facility failed to ensure 1 of 1 stairway enclosure doors in PACU were in accordance with 7.2. LSC Section 7.2.1.5.10 requires a latch or other fastening device on a door leaf to be provided with a releasing device that has an obvious method of operation and is readily operated under all lighting conditions. This deficient practice affects at least 10 patients in PACU, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 8 of 17 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier. NFPA 101 2012 edition 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC 8.5. 8.5.2.2 States smoke barriers required by this code shall be continuous from outside wall to outside wall, from floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof. 8.5.6.2 Requires penetrations for cable, conduit, pipe, or wire...of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke. This deficient practice affects all patients on the first, second, third, and fifth floors.

Building 07:

Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm system in accordance with 4.5.6. LSC 4.5.6 any fire protection system, building service equipment, feature of protection, or safe-guard provided to achieve the goals of this Code shall be designed, installed, and approved in accordance with applicable NFPA standards. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 edition, Table 5.1.1.2 indicates the required frequency of inspection and testing. This deficient practice could affect all occupants, the facility failed to ensure 1 of 1 Pharmacy Sink was provided with a ground fault circuit interrupter (GFCI) protection against electric shock. LSC sections 9.1.2 requires all electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, Article 210.8 Ground-Fault Circuit-Interrupter Protection for Personnel, in 210.8(A), Dwelling Units, requires ground-fault circuit-interrupter (GFCI) protection for all personnel in bathrooms and kitchens where the receptacles are intended to serve the countertop surfaces. Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice could affect staff only.

Building 09:

Based on observation and interview, the facility failed to ensure 1 of 1 sprinkler system in accordance with 4.5.6. LSC 4.5.6 any fire protection system, building service equipment, feature of protection, or safe-guard provided to achieve the goals of this Code shall be designed, installed, and approved in accordance with applicable NFPA standards. NFPA 25, 2011 Edition, 5.3.2.1 states gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. This deficient practice could affect all occupants, the facility failed to ensure 1 of 1 sprinkler system in accordance with 4.5.6. LSC 4.5.6 any fire protection system, building service equipment, feature of protection, or safe-guard provided to achieve the goals of this Code shall be designed, installed, and approved in accordance with applicable NFPA standards. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 edition, Table 5.1.1.2 indicates the required frequency of inspection and testing. This deficient practice could affect all occupants.

Building 10:

Based on observation and interview, the facility failed to ensure doors in 1 of 1 PACU fire barrier wall were eqiopped with positive latches. This deficient practice could affect staff and up to 4 patients, the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 21.3.4.1. NFPA 72, 17.7.4.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect staff and up to 4 patients, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 1 of 6 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier. LSC Section 21.3.7.5 requires smoke barriers to be constructed in accordance with LSC Section 8.5 and shall have a minimum ½ hour fire resistive rating. This deficient practice could affect staff and at least 4 patients, the facility failed to ensure 2 of 6 sets of smoke barrier doors would self-close. This deficient practice could affect staff all occupants in the suite.



Findings include:

Building 01:

1. Based on observations during a tour of the facility with the Maintenance Supervisor on 08/15/18 at 3:00 p.m., the second floor fire doors that separated the hospital form the lobby/gift shop foyer did not latch when tested. Based on interview at the time of observation, the Maintenance Supervisor stated one of the fire door leaves were sticking causing the door not to fully self-close and latch.

2. Based on observation during the tour of the facility with the Plant Engineer on 08/16/18 at 11:29 a.m., the PACU stairwell exit door did not latch into the frame due to the latching hardware not functioning properly. Based on interview at the time of observation, the Maintenance Director stated the latch was sticking in the door and needed adjusting. Based on interview at the time of observation, the Plant Engineer stated the door was not latching.

3. Based on observations during a tour of the facility with the Maintenance Supervisor on 08/15/18 at 2:40 p.m., there were 26 dry pendent type sprinklers, a sprinkler secured in an extension nipple that has a seal at the inlet end to prevent water from entering the nipple until the sprinkler operates, under the main entrance canopy. Based on documentation review with the Assistant Director of Facilities and the Director of Facilities at 10:23 a.m., no documentation was available for review to show a 10 year representative sample testing of the facility's dry pendent sprinklers or if they have been replaced. During an interview at the time of record review and observation, the Director of Facilities, Maintenance Supervisor and Director of Facilities stated there were dry pendent type sprinklers under the front canopy, they have been installed more than 10 years ago, and no written documentation available to show if the sprinklers had been tested or replaced in the last 10 years.

4. Based on observations during a tour of the facility with the Maintenance Supervisor and the Plant Engineer on 08/15/18 between 1:00 p.m. and 4:15 p.m. and on 08/16/18 between 10:20 a.m. and 12:00 p.m., the following smoke barrier walls had unsealed penetrations:
a) Above the ceiling tiles of the smoke barrier wall by ER room 12 there were two unsealed half inch penetration around pipes and conduits.
b) Above the ceiling tiles of the ER waiting room smoke barrier wall there were fire pillows in a large opening around duct work. The fire pillows did not have proper compression leaving visible gaps up to a half inch
c) Above the ceiling tiles of the third floor respiratory smoke wall there was a one inch pipe sleeve containing wires the was unsealed.
d) Above the ceiling tiles of the third floor smoke barrier wall by the north nurses station there were 5 penetration around wires filled with insulation and not sealed with an approved fire rated material.
e) Above the ceiling tiles of the third floor smoke barrier wall by the north nurses station there were fire pillows in a large opening around duct work. The fire pillows did not have proper compression leaving visible gaps up to a half inch.
f) Above the ceiling tiles of the fifth floor smoke barrier wall by room 549 there were three unsealed quarter inch penetrations around conduits.
g) Above the ceiling tiles of the fifth floor smoke barrier wall by room 557 there was an unsealed eighth of an inch penetration around a wire.
h) Above the ceiling tiles of the fifth floor smoke barrier wall by room 557 there was a gap between two pieces of dry wall quarter inch wide and eight inches long.
i) Above the ceiling tiles of the fifth floor smoke barrier wall by the purple elevators there was an unsealed quarter inch penetration around a conduit
j) Above the ceiling tiles of the PACU smoke barrier wall there were five unsealed quarter inch penetrations around conduits.
Based on interview at the time of observations, the Maintenance Supervisor and/or the Plant Engineer agreed there were unsealed penetrations and gaps in the aforementioned smoke barrier walls and provided the measurements of the gaps and penetrations. The Maintenance Supervisor did have maintenance staff fill some of the smaller penetrations with fire caulk

Building 07:

1. Based on record review with the Plant Engineer on 08/15/18 between 2:06 p.m. and 2:36 p.m., no documentation was available for the sprinkler system being inspected, tested, and maintained. Based on interview at the time of record review, the Plant Engineer acknowledged the lack of documentation.

2. Based on observation with the Plant Engineer on 08/15/18 at 2:26 p.m., the Pharmacy had one GFCI receptacle within three feet of the hand sink. When the GFCI tester button was pressed, power was not interrupted on the GFCI receptacle. Based on interview at the time of observation, the Plant Engineer confirmed the outlet was not protected.

Building 09:

1. Based on record review with the Plant Engineer on 08/15/18 at 2:58 p.m., two sprinkler gauges had a manufacturer date 2006 documented. Based on interview at the time of observation, the Plant Engineer confirmed the date on the sprinkler gauges.

2. Based on record review with the Plant Engineer on 08/15/18 at 2:58 p.m., no documentation was available for the sprinkler system being inspected, tested, and maintained. Based on interview at the time of record review, the Plant Engineer acknowledged the lack of documentation.

Building 10:

1. Based on observation with the Plant Engineer on 08/15/18 at 1:58 p.m., the PACU fire barrier doors did not have latching hardware installed. Holes were discovered in the door frame where latching hardware might have been. Based on interview at the time of observation, the Plant Engineer confirmed the latching hardware may have been removed during a remodel process.

2. Based on observation with the Plant Engineer on 07/15/18 at 12:50 p.m., entering the service corridor from the Suite 200 entrance had a ceiling vent sixteen inches from a smoke detector. Based on interview at the time of observation, the Plant Engineer acknowledged the smoke detector was located in a direct airflow or closer than 36 inches from an air supply diffuser or return air opening.

3. Based on observations with the Plant Engineer on 08/15/18 at 1:49 p.m., a quarter inch gap in the smoke barrier above the drop ceiling near the communication closet. Based on interview at the time of observation, the Plant Engineer acknowledged the aforementioned penetration and provided the measurement.

4. Based on record review with the Plant Engineer on 08/15/18, the Plant Engineer identified all smoke barriers in the suite. Based on observation at 12:45 p.m. then again at 2:04 p.m., when tested one of the Suite 200 smoke barrier doors did not self-close. Additionally, one of the double doors contained an astragal but no coordinating device to ensure the door with an astragal, always closes last. Then again, the smoke barrier by the Unit Staff Manager office contained an astragal but no coordinating device Based on interview at the time of observation, the Plant Engineer confirmed one door failed to self-close and no coordinating device was installed on either set of doors.

Building 01:

Based on observation and interview, the facility failed to ensure 2 of 2 ER corridor means of egresses were continuously maintained free of obstructions and did not reduce the corridor width by 60 inches. LSC 19.2.3.4 (4) states projections into the required width shall be permitted for wheeled equipment, provided that all of the following conditions are met:
(a) The wheeled equipment does not reduce the clear unobstructed corridor width to less than 60 inches.
(b) The health care occupancy fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency.
(c) The wheeled equipment is limited to the following:
i. Equipment in use and carts in use
ii. Medical emergency equipment not in use
iii. Patient lift and transport equipment.
This deficient practice could affect 25 patients in the ER, the facility failed to ensure the means of egress through 1 of 1 delayed egress locks on the third floor was readily accessible for all patients, staff, and visitors. LSC 7.2.1.6.1.(3) (4) states a readily visible, durable sign in letters not less than 1 in. (25mm) high and not less than 1/8 in. (3.2mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress:
"PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPENED IN 15 SECONDS".
This deficient practice could affect 20 patients on the third floor, the facility failed to ensure the failure of any single lighting fixture outside of 1 of 2 imaging emergency exits would not leave the area an illumination level of less than 0.2 foot candle (2.2 lux) of 1 of 9 exits in accordance with LSC 7.8.1.4. This deficient practice could affect all staff in imaging using door two in event of an emergency, the facility failed to ensure the corridor door to 2 of 5 hazardous storage rooms in ER and 1 of 10 hazardous storage rooms on floor two was provided with a self-closing device which would cause the door to automatically close and latch into the door frame, the facility failed to ensure complete automatic sprinkler system was provided for 1 of 1 third floor housekeeping mop rooms in accordance with NFPA 13-2010, Standard for the Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. This deficient practice could affect up to 5 patients and visitors that use the elevators by the third floor mop closet, the facility failed to ensure only one type of sprinkler head i.e. quick response or standard sprinklers were installed in 1 of 1 office lobbies and 1 of 4 birthing center storage rooms. NFPA 13, 2010 Edition, Installation of Sprinkler Systems, 8.3.3.4 states when existing light hazard systems are converted to use quick response or residential sprinklers, all sprinklers in a compartmented space shall be changed. This deficient practice could affect 5 patients that use the perioperative clinic and 10 patients in the birthing center, the facility failed to ensure 1 of 2 sets of smoke barrier doors in the ER were self-closing or automatic-closing in accordance with LSC, Section 19.3.7.8 which requires that doors in smoke barriers shall comply with LSC, Section 8.5.4. LSC, 8.4.3.5 Doors shall be self-closing or automatic-closing in accordance with 7.2.1.8. LSC 7.2.1.8.1 states a door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2, unless otherwise permitted by 7.2.1.8.3. This deficient practice affects 25 patients in the ER, the facility failure to ensure 1 of 1 approved portable space heaters were not used in the facility. This deficient practice could affect staff in the Receiving/Distribution Center, the facility failed to ensure 5 of 5 flexible cords were not used as a substitute for fixed wiring to provide power equipment with a high current draw or over loaded. NFPA-70/2011, 400.8 state unless specifically permitted in 400.7 flexible cords and cables shall not be used for (1) as a substitute for fixed wiring. This deficient practice could affect staff in the I.T. and receiving offices, the facility failed to ensure 1 of 1 flexible cords were installed properly and used in a safe manor. NFPA 99, Section 10.2.4.2 states adapters and extension cords meeting the requirements of 10.2.4.2.1 through 10.2.4.2.3 shall be permitted. Section 10.2.4.2.3 states the cabling shall comply with 10.2.3. Section 10.2.3.5.1 states cord strain relief shall be provided at the attachment of the power cord to the appliance so that mechanical stress, either pull, twist, or bend, is not transmitted to internal connections. This deficient practice could affect 5 patients and visitors that would use elevator eight.

Building 10:

Based on observation and interview, the facility failed to maintain 2 of 6 corridors from obstructions per 21.2.1 LSC 21.2.1 states that every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 21.2.2 through 21.2.11. LSC 7.1.10. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. LSC 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto, egress therefrom, or visibility thereof. This deficient practice could affect staff and up to 4 patients.

Findings include:

Building 01:

1. Based on observations during a tour of the facility with the Maintenance Supervisor on 08/15/18 between 1:20 p.m. and 1:40 p.m., in both ER corridors the following items were obstructing corridor egress:
a) There were three stools used by staff in the halls without wheels.
b) There was a room chair in the hall.
c) There were five beds on wheels in the hall which are used for overflow patients, but the beds were on both sides of the hall reducing the corridor width less than 5 feet.
d) There were staff computers and chairs with wheels, but they were on both side of the corridor which reduced the corridor width less than 5 feet.
Based on an interview at the time of observations, the Maintenance Supervisor stated there where stools and a chair in the hall and wheeled equipment were on both sides of the halls.

2. Based on observations during tour of the facility with the Maintenance Supervisor and Plant Engineer on 08/16/18 at 10:30 a.m., the door to critical care was marked as a path of egress, was provided with delayed egress locks, but lacked the proper signage indicating the doors can be opened in 15 seconds by pushing on the door. Based on interview at the time of observation, the Maintenance Supervisor and Plant Engineer stated the door was equipped with a delayed egress and did not post the sign in order to keep unauthorized people out of critical care.

3. Based on observations during a tour of the facility with the Maintenance Supervisor on 08/15/18 at 2:22 p.m., outside the imaging door two exit there was only one light fixture that contained only one single light bulb. Based on interview at the time of observation, the Maintenance Supervisor confirmed the door was an exit, only had one light source, and the one light source had only one bulb.

4. Based on observations during a tour of the facility with the Maintenance Supervisor on 08/15/18 between 1:00 p.m. and 3:40 p.m., the following hazardous rooms which contained hazardous chemicals or combustible storage in a room greater than 50 square feet did not have corridor doors that were equipped with a fully working self-closing device:
a) The ER housekeeping closet did not self-close due to the self-closure device was disconnected.
b) The Radiology housekeeping closet did not self-close due to the self-closure device was disconnected.
c) Room 233 was used for storage of 30 plus boxes and the door did was not equipped with a self-closing device.
Based on interview at the time of observations, the Maintenance Supervisor agreed both housekeeping room did contained chemical storage and the doors did not self-close due to the self-closing devices were disconnected. The Maintenance Supervisor did have maintenance personnel reconnect the self-closing device. Also, the Maintenance Supervisor stated that room 233 was being used for combustible storage and the door to the room was not self-closing.

5. Based on observations during a tour of the facility with the Maintenance Supervisor on 08/16/18 at 10:31 a.m., the third floor housekeeping mop closet by elevators 8-9 did not contain a sprinkler head. Based on an interview at the time of observation, the Maintenance Supervisor agreed there was no sprinkler head in the mop closet, and during the exit conference the Director of Facilities stated the original room was larger and a wall was constructed to close off the mop sink. The sprinkler head was on the other side of the constructed wall.

6. Based on observations during a tour of the facility with the Maintenance Supervisor on 08/15/18 at 2:30 p.m. and on 08/16/18 at 11:14 a.m., the following areas were mixed with standard and quick response sprinklers:
a) The Perioperative Clinic lobby contained two quick response and three standard response.
b) The Family Birthing store room contained one quick response and one standard response.
Based on an interview at the time of observations, the Maintenance Supervisor confirmed the Perioperative Clinic lobby and the Family Birthing store room contained a mix of quick response and standard response sprinklers.

7. Based on observations during a tour of the facility with the Maintenance Supervisor on 08/15/18 between at 1:33 p.m., the smoke barrier door by room 12 was blocked from self-closing by a medical cart. Based on interview at the time of observation, the Maintenance Supervisor stated the cart blocking the smoke door belongs to the Respiratory Department and had Respiratory staff remove the cart that was blocking the smoke door.

8. Based on observations with the Plant Engineer on 08/15/18 at 4:03 p.m., a portable space heater was noted in the Receiving/Distribution Center. The space heater contained exposed heating elements which would exceed the maximum allowed temperature. Also, the portable space heater did not state the maximum temperature achieved by the unit. Based on interview at the time of the observations, the Plant Engineer agreed a portable space heater was used that contained exposed heating elements and it was not a space heater approved by the hospital.

9. Based on observations during a tour of the facility with the Facilities Director and the Environmental Care Coordinator on 10/01/16 between 12:00 p.m. and 3:00 p.m., the following misuse of power strips were observed:
a) High powered draw equipment such as microwave, refrigerator, and coffee pot was plugged in to a power strip in the I.T. office.
b) High powered draw equipment such as microwave, refrigerator, and coffee pot was plugged in to a power strip in receiving/distribution center.
c) In the I.T. office. 2 sets of power strips were over loaded due to the power strips were full and a second fully used power strip was plugged into them.
d) In the I.T. closet by the Cyber Café a power strip was over loaded due to the power strip was full and a second fully used power strip was plugged into it.
Based on interview at the time of observations, the Maintenance Director did ager the aforementioned locations contained power strips that were over loaded by high power draw equipment and plugging in a second power strip.

10. Based on observations during a tour of the facility with the Maintenance Supervisor on 08/16/18 at 11:00 a.m., in the fourth floor I.T. closet by elevator eight contained a power strip used to power I.T. equipment was not secured and dangling from the form the outlet on the top half of the wall. This condition could put stress on the power cord causing damage to the power cord and the outlet. Based on interview at the time of observations, the Maintenance Supervisor agreed the power strip was dangling from an outlet, not secured, and stated the power strip will need to be mounted.

Building 10:

1. Based on observation with the Plant Engineer on 08/15/18 at 1:09 p.m. then again at 1:20 p.m., four separate soiled linen containers were in the corridor outside Pre-op room 3. Then again, a trash can was in the corridor outside of the Surgical Supply room. Based on interview at the time of each observation, the Plant Engineer acknowledged that impediments such as the soiled linen containers and the trash can were potential impediments to full use of the means of egress access corridors.