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Based on Observation it was determined the facility failed to provide a clear means of egress to exit to a public way. Failure to provide a clear and unimpeded means of egress could cause harm to the patients and staff in a fire emergency.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10.1 " 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." Section 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto egress there from, or visibility thereof.

Observations while on tour November 14-15, 2023, revealed the hospital failed to maintain a clear path to the exit in the following areas.
1. Med-Surg had equipment such as tray tables. computer carts, and linen baskets in the exit corridor
2. The Radiology exit corridor had chairs being used for documenting in the exit pathway
3. The basement area had Bio Hazard carts being stored in the exit pathway.

Employees # 1 and #2 confirmed during the tour that the above-listed exit pathways were restricted.
Employee's #1, #2, #3, and #4 acknowledged during the exit interview that the facility had restricted exit pathways.

Based on the findings discovered during the walkdown the facility failed to provide battery-operated emergency lighting to all EPS equipment locations. Failing to install, test, and document the battery backup emergency lighting units in case of an emergency or power outage could cause harm to the patients during a power outage.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.9.1 "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " Section 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) The Test interval shall be permitted to be extended beyond 30 days with the approval of authority having jurisdiction.(3) Functional testing shall be conducted annually for a minimum of 1/1/2 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.

NFPA 110: Standard for Emergency and Standby Power Systems, 2010 Edition - Chapter 7 Installation and Environmental Considerations
7.3 Lighting. 7.3.1 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access.

Findings include:

Observations while on tour on November 14, 2023, revealed the automatic transfer switch room was not equipped with battery-operated emergency lighting. The facility installed the equipment on the day of this discovery.

Employees #1 and #2 acknowledged during the walk down and at the exit conference that the ATS room was not equipped with battery-operated emergency lighting.
Employee's #1, #2, #3, and #4 acknowledged during the exit interview that the facility was missing emergency lighting in the ATS room..