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Based on observation the facility failed to maintain the smoke/fire resistive rating of corridor walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

Findings Include:

On September 18, 2012 the surveyor, accompanied by the Coordinator, Facilities Management, and the Safety Officer, observed that there are penetrations in the corridor wall located above Room 203, to include a penetration around the conduit in the ice room by room 216 of the facility.

During the exit conference on September 18, 2012 the above findings were again acknowledged by the Chief Medical Officer, Assistant Administrator, Administration, Chief Nursing Officer/Chief Clinical Officer, Coordinator, Facilities Management and the Safety Officer.

Corridor walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat will cause harm to the patients.

Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On September 18, 2012 the surveyor, accompanied by the Coordinator, Facilities Management, and the Safety Officer, observed the following corridor doors would not tightly close when tested.

1. Room 220, door will not positively latch
2. Room 222, door will not positively latch
3. Room 224, door will not positively latch
4. Room 226, door will not positively latch
5. Room 231, door will not positively latch
6. Lab office/equipment wash area, rated door with a closing device will not positively latch when tested three of three times
7. Endoscope Room 1, door does not positively latch
8. GI and OR Lab break room, door does not positively latch and does not have a latching mechanism
9. ER Nurses station/Doctors office, rated door held open with an impediment

During the exit conference on September 18, 2012 the above findings were again acknowledged by the Chief Medical Officer, Assistant Administrator, Administration, Chief Nursing Officer/Chief Clinical Officer, Coordinator, Facilities Management and the Safety Officer.

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation the facility failed to maintain self closing doors in a smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Findings include:

On September 18, 2012 the surveyor, accompanied by the Coordinator, Facilities Management, and the Safety Officer, observed the following corridor smoke/fire doors would not close tight:

1. Smoke barrier door by Environmental services, gap approximately 1/4 inch
2. Smoke barrier doors by room 203, will not close tight, gap greater than 1 3/4 inch

During the exit conference on September 18, 2012 the above findings were again acknowledged by the Chief Medical Officer, Assistant Administrator, Administration, Chief Nursing Officer/Chief Clinical Officer, Coordinator, Facilities Management and the Safety Officer.


This installation will allow smoke to contaminate smoke zones not directly effected by the fire, which will cause harm to patients.

Based on observation the facility failed to keep the laundry room dryers clean.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.1. "Equipment using gas and related gas piping shall be installed in accordance with NFPA 54 " National Fuel Gas Code" or NFPA 58 " Liquefied Petroleum Gas Code" , NFPA 54 Chapter 6, Section 6.4 "Clothes Dryers Section 6.4.5 (c) Type 2 Clothes Dryers shall be equipped or installed with lint controlling means. "

Findings include:

On September 18, 2012 the surveyor, accompanied by the Coordinator, Facilities Management, and the Safety Officer, observed the dryer in the EVS laundry room had an excessive amount of lint in the dryer frame assemblies, behind the dryers, and the floor area.

During the exit conference on September 18, 2012 the above findings were again acknowledged by the Chief Medical Officer, Assistant Administrator, Administration, Chief Nursing Officer/Chief Clinical Officer, Coordinator, Facilities Management and the Safety Officer.

Failing to insure proper cleaning of the lint could cause a fire and cause harm to the patients.

Based on observation the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 19.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

Findings include:

On September 18, 2012 the surveyor, accompanied by the Coordinator, Facilities Management, and the Safety Officer, observed storage of, two large chairs, portable X-ray machine, two types of weight scales, two types of equipment carts, within the exit corridor. The storage was blocking the exit access located by ER/Rooms two and three in the East/ West Exit corridor.

During the exit conference on September 18, 2012 the above findings were again acknowledged by the Chief Medical Officer, Assistant Administrator, Administration, Chief Nursing Officer/Chief Clinical Officer, Coordinator, Facilities Management and the Safety Officer.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

Based on Record Review the facility failed to complete sensitivity testing on the facilities smoke detectors.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.1.1.1.1, "The requirements of this chapter apply to existing buildings or portions thereof currently occupied as health care. Existing health care facilities shall comply with the provisions of this chapter" Chapter 19, Section 19.3.4.1 "General" "Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.", Chapter 9, Section 9.6.1.4. 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 Code. NFPA 101, Chapter 4, Section 4.6.12.3, " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 72 National Fire Alarm Code, Chapter 7 Inspection Testing, and Maintenance/Paragraph 7-3.2 "Testing shall be performed in accordance with the schedules in this chapter or more frequently where required by authority having jurisdiction. Section 7-3.2.1 "Detectors sensitivity shall be checked within 1 year after installation and every alternate year thereafter. Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and revalidated or be replaced."

Findings include:

On September 18, 2012 the surveyor, accompanied by the Coordinator, Facilities Management, and the Safety Officer, reviewed the fire alarm inspection report by Central Alarm, dated December 22, 2011. The report did not indicate the U.L. sensitivity of the smoke detectors or if the smoke detectors passed the required sensitivity range. The most recent sensitivity report was dated March 5, 2008 completed by Central Alarm.


During the exit conference on September 18, 2012 the above findings were again acknowledged by the Chief Medical Officer, Assistant Administrator, Administration, Chief Nursing Officer/Chief Clinical Officer, Coordinator, Facilities Management and the Safety Officer.


Failure to test and maintain the fire alarm systems smoke detectors could result in harm to the patients.

Based on Observation the facility failed to provide protection for the exterior oxygen cylinder storage.
Based on observation the facility failed to mount an electrical light switch five feet above the floor in the oxygen storage room.


NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.4. "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. NFPA 99, Chapter 4, Section 4-3.5.2.2, (3) "Cylinders stored in the open shall be protected against extremes of weather and from the ground beneath to prevent rusting. During winter; cylinders stored in the open shall be protected against accumulations of ice or snow. In summer; cylinders stored in the open shall be screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail." Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage.

Findings include:

On September 18, 2012 the surveyor, accompanied by the Coordinator, Facilities Management, and the Safety Officer, observed the following Oxygen storage procedures:

1. Outside Oxygen storage area next to LOX plant, Newly installed H tank cascade system of ten tanks, no protection from continuous exposure to direct rays of the sun
2. O2 closet storage, Electrical switch when measured at 50 inches
3. Room 220, vacant patient room, storage of one E- O2 cylinder
4. Med supply/Med Surgery room, by room 230, two E-O2 bottles stored by electrical outlet and combustibles
5. Room 231, vacant patient room, storage of one E O2 cylinder
6. Cardio Pulmonary eight E-O2 bottles stored by combustibles

During the exit conference on September 18, 2012 the above findings were again acknowledged by the Chief Medical Officer, Assistant Administrator, Administration, Chief Nursing Officer/Chief Clinical Officer, Coordinator, Facilities Management and the Safety Officer.

Failing to mount a light switch five feet above the floor to prevent an accident/or possible fire could cause harm to the patients.
Failing to protect exterior stored medical gas cylinders from rust, snow/ice or sun may cause harm to the patients.

Based on Observation the facility failed to provide battery operated emergency lighting in the operating rooms, anesthetizing locations.
Based on Observation the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1 "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2 "Electric wiring and equipment shall be in accordance with NFPA 70 National Electrical Code... Article 517 Health Care Facilities, Section 517-63 Grounded Power systems in Anesthetizing Locations. 517-63(a), 'Battery-Powered Emergency Lighting Units." "One or more battery-powered emergency lighting units shall be provided in accordance with Section 700-12(e)." NFPA 99, Health Care Facilities, Chapter 3, Section 3-3.2.1.2, (5) Wiring in Anesthetizing Locations. (e) Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, Section 700-12 (e). Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

On September 18, 2012 the surveyor, accompanied by the Coordinator, Facilities Management, and the Safety Officer, observed the Operating Rooms in the Hospital. None of the Operating rooms were protected with battery powered emergency lighting.
The facilities allowed refrigerators and microwaves plugged into multi-outlet power strips and not directly plugged in to the wall outlet receptacles in the following rooms:

1. Facilities Office, microwave plugged into power strip
2. Med/Surgery Nurses break room, refrigerator and microwave plugged into power strip
3. Cardio Pulmonary, refrigerator and microwave plugged into power strips
4. To include MRI trailer one of two emergency lights inoperative

During the exit conference on September 18, 2012 the above findings were again acknowledged by the Chief Medical Officer, Assistant Administrator, Administration, Chief Nursing Officer/Chief Clinical Officer, Coordinator, Facilities Management and the Safety Officer.

Failing to provide battery-powered emergency lighting in the operating rooms will harm patients during a power outage and failure of the emergency generator.
The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

Based on observation the facility failed to maintain the smoke/fire resistive rating of corridor walls.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.1, "Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (See also 19.2.5.9) (See all Exceptions) Section 19.3.6.2 "Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour." (See all Exceptions}.

Findings Include:

On September 18, 2012 the surveyor, accompanied by the Coordinator, Facilities Management, and the Safety Officer, observed that there are penetrations in the corridor wall located above Room 203, to include a penetration around the conduit in the ice room by room 216 of the facility.

During the exit conference on September 18, 2012 the above findings were again acknowledged by the Chief Medical Officer, Assistant Administrator, Administration, Chief Nursing Officer/Chief Clinical Officer, Coordinator, Facilities Management and the Safety Officer.

Corridor walls must remain smoke tight/fire resistive to prevent smoke and heat from entering resident rooms. Smoke/heat will cause harm to the patients.

Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.1, 19.3.6.3.2, 19.3.6.3.3. Section 19. 19.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 19.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 19.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On September 18, 2012 the surveyor, accompanied by the Coordinator, Facilities Management, and the Safety Officer, observed the following corridor doors would not tightly close when tested.

1. Room 220, door will not positively latch
2. Room 222, door will not positively latch
3. Room 224, door will not positively latch
4. Room 226, door will not positively latch
5. Room 231, door will not positively latch
6. Lab office/equipment wash area, rated door with a closing device will not positively latch when tested three of three times
7. Endoscope Room 1, door does not positively latch
8. GI and OR Lab break room, door does not positively latch and does not have a latching mechanism
9. ER Nurses station/Doctors office, rated door held open with an impediment

During the exit conference on September 18, 2012 the above findings were again acknowledged by the Chief Medical Officer, Assistant Administrator, Administration, Chief Nursing Officer/Chief Clinical Officer, Coordinator, Facilities Management and the Safety Officer.

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation the facility failed to maintain self closing doors in a smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Findings include:

On September 18, 2012 the surveyor, accompanied by the Coordinator, Facilities Management, and the Safety Officer, observed the following corridor smoke/fire doors would not close tight:

1. Smoke barrier door by Environmental services, gap approximately 1/4 inch
2. Smoke barrier doors by room 203, will not close tight, gap greater than 1 3/4 inch

During the exit conference on September 18, 2012 the above findings were again acknowledged by the Chief Medical Officer, Assistant Administrator, Administration, Chief Nursing Officer/Chief Clinical Officer, Coordinator, Facilities Management and the Safety Officer.


This installation will allow smoke to contaminate smoke zones not directly effected by the fire, which will cause harm to patients.

Based on observation the facility failed to keep the laundry room dryers clean.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.1. "Equipment using gas and related gas piping shall be installed in accordance with NFPA 54 " National Fuel Gas Code" or NFPA 58 " Liquefied Petroleum Gas Code" , NFPA 54 Chapter 6, Section 6.4 "Clothes Dryers Section 6.4.5 (c) Type 2 Clothes Dryers shall be equipped or installed with lint controlling means. "

Findings include:

On September 18, 2012 the surveyor, accompanied by the Coordinator, Facilities Management, and the Safety Officer, observed the dryer in the EVS laundry room had an excessive amount of lint in the dryer frame assemblies, behind the dryers, and the floor area.

During the exit conference on September 18, 2012 the above findings were again acknowledged by the Chief Medical Officer, Assistant Administrator, Administration, Chief Nursing Officer/Chief Clinical Officer, Coordinator, Facilities Management and the Safety Officer.

Failing to insure proper cleaning of the lint could cause a fire and cause harm to the patients.

Based on observation the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 19.2.3.3 "Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width". Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

Findings include:

On September 18, 2012 the surveyor, accompanied by the Coordinator, Facilities Management, and the Safety Officer, observed storage of, two large chairs, portable X-ray machine, two types of weight scales, two types of equipment carts, within the exit corridor. The storage was blocking the exit access located by ER/Rooms two and three in the East/ West Exit corridor.

During the exit conference on September 18, 2012 the above findings were again acknowledged by the Chief Medical Officer, Assistant Administrator, Administration, Chief Nursing Officer/Chief Clinical Officer, Coordinator, Facilities Management and the Safety Officer.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

Based on Record Review the facility failed to complete sensitivity testing on the facilities smoke detectors.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.1.1.1.1, "The requirements of this chapter apply to existing buildings or portions thereof currently occupied as health care. Existing health care facilities shall comply with the provisions of this chapter" Chapter 19, Section 19.3.4.1 "General" "Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.", Chapter 9, Section 9.6.1.4. 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 Code. NFPA 101, Chapter 4, Section 4.6.12.3, " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 72 National Fire Alarm Code, Chapter 7 Inspection Testing, and Maintenance/Paragraph 7-3.2 "Testing shall be performed in accordance with the schedules in this chapter or more frequently where required by authority having jurisdiction. Section 7-3.2.1 "Detectors sensitivity shall be checked within 1 year after installation and every alternate year thereafter. Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and revalidated or be replaced."

Findings include:

On September 18, 2012 the surveyor, accompanied by the Coordinator, Facilities Management, and the Safety Officer, reviewed the fire alarm inspection report by Central Alarm, dated December 22, 2011. The report did not indicate the U.L. sensitivity of the smoke detectors or if the smoke detectors passed the required sensitivity range. The most recent sensitivity report was dated March 5, 2008 completed by Central Alarm.


During the exit conference on September 18, 2012 the above findings were again acknowledged by the Chief Medical Officer, Assistant Administrator, Administration, Chief Nursing Officer/Chief Clinical Officer, Coordinator, Facilities Management and the Safety Officer.


Failure to test and maintain the fire alarm systems smoke detectors could result in harm to the patients.

Based on Observation the facility failed to provide protection for the exterior oxygen cylinder storage.
Based on observation the facility failed to mount an electrical light switch five feet above the floor in the oxygen storage room.


NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.4. "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. NFPA 99, Chapter 4, Section 4-3.5.2.2, (3) "Cylinders stored in the open shall be protected against extremes of weather and from the ground beneath to prevent rusting. During winter; cylinders stored in the open shall be protected against accumulations of ice or snow. In summer; cylinders stored in the open shall be screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail." Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage.

Findings include:

On September 18, 2012 the surveyor, accompanied by the Coordinator, Facilities Management, and the Safety Officer, observed the following Oxygen storage procedures:

1. Outside Oxygen storage area next to LOX plant, Newly installed H tank cascade system of ten tanks, no protection from continuous exposure to direct rays of the sun
2. O2 closet storage, Electrical switch when measured at 50 inches
3. Room 220, vacant patient room, storage of one E- O2 cylinder
4. Med supply/Med Surgery room, by room 230, two E-O2 bottles stored by electrical outlet and combustibles
5. Room 231, vacant patient room, storage of one E O2 cylinder
6. Cardio Pulmonary eight E-O2 bottles stored by combustibles

During the exit conference on September 18, 2012 the above findings were again acknowledged by the Chief Medical Officer, Assistant Administrator, Administration, Chief Nursing Officer/Chief Clinical Officer, Coordinator, Facilities Management and the Safety Officer.

Failing to mount a light switch five feet above the floor to prevent an accident/or possible fire could cause harm to the patients.
Failing to protect exterior stored medical gas cylinders from rust, snow/ice or sun may cause harm to the patients.

Based on Observation the facility failed to provide battery operated emergency lighting in the operating rooms, anesthetizing locations.
Based on Observation the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1 "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2 "Electric wiring and equipment shall be in accordance with NFPA 70 National Electrical Code... Article 517 Health Care Facilities, Section 517-63 Grounded Power systems in Anesthetizing Locations. 517-63(a), 'Battery-Powered Emergency Lighting Units." "One or more battery-powered emergency lighting units shall be provided in accordance with Section 700-12(e)." NFPA 99, Health Care Facilities, Chapter 3, Section 3-3.2.1.2, (5) Wiring in Anesthetizing Locations. (e) Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, Section 700-12 (e). Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

On September 18, 2012 the surveyor, accompanied by the Coordinator, Facilities Management, and the Safety Officer, observed the Operating Rooms in the Hospital. None of the Operating rooms were protected with battery powered emergency lighting.
The facilities allowed refrigerators and microwaves plugged into multi-outlet power strips and not directly plugged in to the wall outlet receptacles in the following rooms:

1. Facilities Office, microwave plugged into power strip
2. Med/Surgery Nurses break room, refrigerator and microwave plugged into power strip
3. Cardio Pulmonary, refrigerator and microwave plugged into power strips
4. To include MRI trailer one of two emergency lights inoperative

During the exit conference on September 18, 2012 the above findings were again acknowledged by the Chief Medical Officer, Assistant Administrator, Administration, Chief Nursing Officer/Chief Clinical Officer, Coordinator, Facilities Management and the Safety Officer.

Failing to provide battery-powered emergency lighting in the operating rooms will harm patients during a power outage and failure of the emergency generator.
The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.