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Based on observation and interview, the facility does not ensure that the exit access corridor in the pathology laboratory is maintained clear and unobstructed.

Findings include:

Observation on 3/25/15 at 2:50 PM during tour of the pathology laboratory area revealed cardboard, equipment and a transport cart stored in the exit access corridor adjacent to room K 203 in the ASB building. Exit access is required to be kept clear of obstructions.

This finding was verified with Director OES Staff #2 on 3/25/15.

Based on observation and interview, the facility does not provide fire safety to patients and staff related to medical gas storage; specifically:
1) The medical gas storage room on the loading dock does not have a one-hour fire rated separation.
2) Electrical outlets, light switches and mechanical devices are not located properly in the medical gas storage room in the physical therapy department.
3) An oxygen tank was not stored properly in the endoscopy suite.

Findings include:

Finding #1:
Observation on 3/24/15 at 12:00 PM during facility tour revealed the door to the medical gas storage room on the loading dock was held open with a wire. Medical gas storage rooms are required to have a one-hour fire rated separation. To maintain this rating, the doors must be closed. Further investigation revealed two hoses for filling the nitrogen storage tank were laying on the floor of the medical gas storage room. The hoses were not coiled or stored to prevent damage.

This finding was verified by Director OES Staff #2 on 3/24/15.

Finding #2:
Observation on 3/24/15 at 12:15 PM during tour of the medical gas storage room located in the physical therapy department revealed electrical outlets, light switches and mechanical devices located less than 60 inches from the floor. Electrical devices, light switches and outlets must be located at a height of 60 inches or more to prevent damage from movement of the gas storage vessels.

This finding was verified by Staff #2 on 3/24/15.

Finding #3:
Observation on 3/26/15 at 11:30 AM during tour of the endoscopy suite revealed an oxygen storage tank (E size) laying on its side under the hand-wash sink in procedure room #3. Oxygen tanks are required to be secured in the upright position.

This finding was verified with Staff #2 on 3/26/15.

Based on observation and interview, the facility does not provide fire safety to patients and staff related to Alcohol Based Hand Rub (ABHR) dispensers in the pathology area.

Findings include:

Observation on 3/25/15 at 3:00 PM during the tour of the Pathology Lab Sign-out room revealed ABHR dispensers mounted on the walls above carpeted floors. This building is non-sprinklered. This regulation prohibits storage of ABHR over carpeting in non-sprinklered buildings.

This finding was verified with Director OES Staff #2 on 3/25/15.