HospitalInspections.org

Based on observations the facility's corridor doors did not always resist the passage the smoke.

Findings

1. On the afternoon of 4/4/11 the main entrance doors to the ED suite did not close and latch and could not resist the passage of smoke due to a gap approximately 1/4" at the meeting edges.

2. On the afternoon of 4/4/11 the double doors between the corridor and the ED suite in the ambulance triage area did not close and latch.

3. On the afternoon of 4/6/11 the entrance doors between the corridor and the surgical intensive care unit did not close and latch and did not resist the passage of smoke. A gap approximately 1/4 " was noted at the meeting edges.

4. On the afternoon of 4/7/11 the ambulatory surgical suite corridor doors did not close, latch or resist the passage of smoke.

Based on observation the hospital did not ensure that vertical separation was maintained.

Findings include:

Plumbing chase

Big gaps between cinderblock walls stairwell MEETH

Dumbwaiter door not latching in SPD

An abandonded vent in the darkroom in the OR site not removed or capped off

Based on observation and staff interview access to exits were not marked by approved, readily visible signs.

Findings are:

1. On the afternoon of 4/4/11 exit signs were not readily visible from all areas of the emergency department (ED) and from treatment room # 2.

2. On the afternoon of 4/4/11 direction of travel from the stairwell providing egress from the kitchen area to discharge at Park Avenue was not clear. Once inside the stair one can travel up the stairs or down. Exit to the public way requires travel up the stairs. No exit sign was provided to direct travel up to the level of discharge. In addition, the stair going down to the basement was not interrupted by a partition, gate or other effective means to prevent travel beyond the level of discharge.

3. On the afternoon of 4/4/11 it was noted that an exit sign was not provided from the clean equipment room (materials management) to the corridor.

Based on observations,record review, and interview during tours of the hospital between 4/4/11 and 4/8/11 the hospital did not ensure that smoke barriers are maintained as required.

Findings include:

1. The smoke barrier doors on the 7 th floor between Wollman / Lachman buildings were noted held open with magnetic hold open devices. The smoke detectors required to ensure that the doors release in the event of a smoke condition were located 12 feet from the door rather than a maximum of 5 feet.

2. Penetrations were noted above the smoke barrier doors adjacent to room 8612.

Based on observations and record review made between 4/4/11and 4/8/11 the hospital did not ensure that hazardous areas are protected as required.

Findings:

1. The materials management storage room was not completely separated. The sheetrock wall did not extend above the deck on all four sides particularly the wall separating this area from the sterilization processing department. Numerous penetrations and incompletely firestopped penetrations were also observed.

2. Observation of the sheetrock wall above the dropped ceiling revealed that Storeroom B and the storage room containing positions equipment, much of which is cushioned with foam padding, were not separated. Storeroom B was only partially sprinklered.

3. Penetrations were noted in the one hour separation in soiled utility room on the 7th floor surgical intensive care unit. The room was not sprinklered.

4. The one hour separation of the rated wall of the basement paint shop were compromised by penetrations.

Based on observation and interview flammable chemicals used by the laboratory are not stored as required.

Findings:

1. On the afternoon of 4/7/11 a closet in the corridor outside the laboratory used to recycle zylene and alcohol lacked one hour separation. The walls of the room did not extend to the deck but only to the dropped ceiling. Approximately 25 gallons of flammable liquids were being recycled and stored in this closet. Confirmed in interview with staff # 14.

2. On the afternoon of 4/7/11 two 10 gallon containers used to collect used zylene and alcohol were noted in the histology lab. No more than one gallon of a flammable liquid is allowed outside a safety cabinet and no more than 2 gallons inside an approved storage cabinet.
NFPA 99 1999 10-7.2.2

Based on observation on the morning of 4/4/11 the hospital did not ensure that exit components were appropriately designed and maintained.

Findings:

1. The rating of exit Stair B doors at the level of discharge was compromised by a gap approximately 1/3 to 1/4 inch at the meeting edges.

2. The gate in stair B installed to prevent travel below the level of discharge was noted hanging off the wall because one of two bolts was missing.

3. The exit door from the kitchen, in the vicinity of the tray line, was noted provided with a prohibited manual pull from the egress side.
NFPA 101 2000 19.2.2.2.4

Dead ends

Based on observation the hospital did not ensure that all exits are readily accessible at all times.

Finding:

The Cafe in the lobby of the 64 th street building restricted the width of the exit corridor. The width of corridor was reduced to 75" on the diagonal.

Based on observation the hospital did not always ensure that two means of egress are provided from rooms greater than 1000 sq. ft. for patient sleeping and 2500 sq. ft for non-sleeping rooms..

Findings:

1. During a tour of the sterile processing department (SPD) on the afternoon of 4/4/11 it was noted that the 2nd exit is from the clean side of the processing is not into a corridor but rather through a heavily congested storage room i.e., a hazardous area, and then back into the decontamination side of the same SPD room. Travel to an exit shall not be through a hazardous area. In addition, travel is through two intervening rooms and the travel distance is greater than 50'.
NFPA 101 2000 18.2.5.5 / 18.2.5.8

2. On the morning of 4/7/11 during a tour of the special care suite on the psychiatric unit it was noted that this sleeping suite was 1472 sq. ft. and had only one exit.

Based on observation not all patient room doors can be opened from the inside without the use of a key.

Finding:

On the morning of 4/7/11 doors to the 8 th floor psychiatric patient sleeping rooms were noted provided with a deadbolt lock not operable from the inside.

Based on record review and staff interview on 4/5/11 and 4/8/1, the hospital did not ensure that all staff members are familiar with fire safety procedures.

Findings:

1. On the morning of 4/5/11 six kitchen staff members were interviewed on fire safety. Five out of six staff members did not know the location of the manual pulls. These included the director and assistant director of nutritional services. Staff members indicated that they would call "5151" in the event of fire.
Some were confused by the blue pull on the wall by the door. This pull is used to open the door and is not a manual pull used to activate the FA system.

2. No documentation was available to show that site specific fire drills in the operating room (OR) suite have been conducted at any time at the 77 th Street and 64 th Street campuses.
NFPA 99 1999 12-4.1.2.10

3. There was no documentation available to show that OR staff were in-serviced on site specific OR fires at the 77 th Street campus.
NFPA 99 1999 12-4.1.2.10

4. Review of the site specific OR fire safety in-service conducted at the 64 th Street campus on 4/6/11 revealed minimal participation by surgeons.
NFPA 99 1999 12-4.1.2.10

5. Review of fire drill records indicate that, except for physicians on the psychiatric unit, physician participation in fire drills is minimal.

Based on record review and interview the hospital did not ensure that all components of the fire alarm (FA) system were maintained in accordance with NFPA 72

Findings:

1. Service reports reveal that when the vendor identified deficiencies the hospital did not always ensure that the deficiency was corrected. Follow up documentation for the following was requested but could not be provided. Examples include but are not limited to:

a. The fire and smoke damper report dated May 16, 2006 stated that 3% of the hospitals dampers failed inspection. This was because dampers were not accessible for testing or were defective.

b. The HVAC fan shutdown report dated July 7-9 2010 showed that approximately 30 devices failed upon activation of the fire alarm system and/or could not be located.

c. A report dated March 24, 2011 for the 64 th Street campus showed that the fire alarm was not activated when the electronic waterflow alarm was tested on the 1st and 2nd floors in Stair C.

d. The backflow valve tamper switch tested on Mar 23, 2011 at the 64 th Street campus actuated only when held down manually.

Note: The hospital was on Fire Watch at both campuses.

2. It could not be determined if all fire safety equipment and components of the FA system that require testing were, in fact, tested because records do not always include an inventory of all devices. There is, for example, no inventory of fire hoses and notification and initiating devices.

3. Based on observations and interview made on the afternoon of 4/8/11 at 3:20 PM during a hospital wide test of the FA system at the 64 th Street campus it was determined that the fire alarm notification system was was not fully functional.

Findings:

a. Two audible / visual notification devises in the PACU located on the 2nd floor did not activate. This observation was confirmed by staff members # 10 and 11.

b. On the sixth floor of the building the overhead announcement that a fire drill was being conducted could not be heard. Audible / visible notification devices did not activated in the area under observation but could be heard in the distance. Confirmed by security staff.

c. The overhead announcement that a fire drill was being conducted could not be heard in the basement.

Based on observation, document review and interview the hospital did not ensure that all the components of the sprinkler system are maintained in accordance with NFPA 25

Findings include but are not limited to:

1. Review of hospital records show that various buildings on the two campuses are > 50 years of age. There was not documentation to show that standard response sprinkler heads, that might be > than 50 years old, were tested within the last ten years. Staff member # 12 stated in interview that the sprinkler heads were tested, however, no documentation could be provided.

2. No documentation was available to show that the 5 year internal inspections for obstructions were conducted on sprinkler piping,, check valves, alarm valves and associated trim.

3. No documentation was available to show that visual inspections of sprinkler heads and visible pipe were conducted. Several overhead sprinkler heads in the materials management room at the 64 th street campus were observed clogged with grease and dust.

4. Review of main drain test results revealed that an hydraulic name plate with residual pressure was not available nor were previous years results available for comparison to determine if there were changes in water pressure or flow.

5. 18" clearance was not provide around sprinkler heads in the plumbing and electrical shops.

Based on observation the hospital did not ensure that the sprinkler system was installed in accordance
with NFPA 13.

Finding:

On the afternoon of 4/4/11 a sprinkler head in the ortho instrumentation area of was observed installed 2" from the wall rather than a minimum of 4".

Based on observations the hospital did not not ensure that all means of egress were continuously maintained to provide full instant use in the event of emergency.

Findings are:

1. On the morning of 4/4/11 the exterior exit passageway from exit B to the public way at 76 th Street was noted obstructed by sheetrock, particle board, joint compound, lumber, containers of joint compound and 2 5 gallon containers of gasoline. In addition, a drain in the exit passageway was clogged and a large pool of water approximately 1" deep was noted.

2. On the afternoon of 4/4/11 the exit passage in the vicinity of the building services store room was noted obstructed by eight 90 gallon transport bins stored along the wall. The transport bins narrowed the with of the passage from six feet wide to three feet wide.

Based on observation the hospital did not ensure that medical gas storage is protected as required.

Finding:

On the afternoon of 4/8/2011 the fire retardant material had fallen off some areas of the Q deck ceiling and steel beams of the manifold room compromising the rating of the room.

Based on record review and interview the hospital failed to ensure that medical gas systems comply with NFPA 99.

Finding is:

Review of medical gas reports on 4/6/11 for both the 77 th street campus and the 64 th street campus, indicated that while both the vendor for the 77 th street campus and the vendor for the 64 th Street campus identified deficiencies there is no documentation to show that corrective action was taken .
This was confirmed in interview with staff member # 12

Based on record review,observation and interview the hospital provides life support equipment but lacks a Type 1 Essential Electrical System (EES).

Findings:

Review of the facility's emergency generator records on 4/7/11 and 4/8/11 indicated that the hospital's generator is not divided into life safety, critical and equipment branches. This was confirmed in interview with Staff # 25.

Cross Refer to K 145

Based on observation not all areas are sprinklered as required.

Findings include:

1. On the afternoon of 4/4/11 the a closet in the support suite adjacent to the administrative suite lacked a sprinkler head.
2. The volunteers work room lacked sprinkler heads.


Based on observation, document review and interview the hospital did not ensure that exit access was arranged so that there were no dead ends greater than 30 feet.

Finding:

On the afternoon of 4/6/11 during a tour of the renovated ICU on the 7 th floor a dead end greater than 30 feet was noted. Travel distance from the end of the corridor to the stair was 60 feet. This was confirmed in interview with staff member # 14. Review of floor plans shows that dead end corridors 60 feet in length exist on the renovated 5th floor CCU, and renovated 8 th and 9 th floor ICUs
NFPA 101 2000 edition 18.2.5.10

Based on observation the hospital did not ensure that combustible liquids are stored in approved cabinets.

Finding:

On the afternoon of 4/8/11 the storage cabinet for flammable liquids in the laboratory at the 64 th Street campus was compromised due to a hole approximately 2" in diameter in its side.

Based on document review and and interview the hospital did not ensure a safe environment in the laboratory.

Finding;

Review of documents revealed that a safety checklist was not available. Interview with laboratory staff indicated that while the hospital employed a laboratory safety office in January 2011 the safety officer has not yet developed a safety checklist.
NFPA 99 1999 10-8.1.3

Based on observation, record review and interview the facility provides general anesthesia, has NFPA 99-1999 defined "Critical Care Areas" (i.e., Operating rooms where NFPA 99 defined "invasive procedures" are performed and patients are connected to line operated patient care-related electrical appliances) and the Essential Electrical System (EES) is not a Type 1 EES in full compliance with NFPA and NFPA 70.

Findings include:

The wiring for items required to be served by the Equipment System was not independent from wiring for items required to be served by the Emergency System and the wiring for items required to be served by the Emergency System - Critical Branch was not separate from the wiring for items required to be served by the Emergency System - Life Safety Branch. Verified in interview with Staff. # 25.

Based on observation the hospital did not ensure that electrical equipment was maintained in accordance with NFPA 70.

Finding:

On the afternoon of 4/7/11 trash was noted stored in the electrical switchgear room. Penetrations were noted in the 2 hour rated walls.

Based on document review and interview elevators do not conform to the requirements of ASME / ANSI A17.3.

Finding:

Elevator records for Category l and Category lV inspections were requested from employee # 12 on the afternoon of 4/7/11 but were not provided.

Based on observations the facility's corridor doors did not always resist the passage the smoke.

Findings

1. On the afternoon of 4/4/11 the main entrance doors to the ED suite did not close and latch and could not resist the passage of smoke due to a gap approximately 1/4" at the meeting edges.

2. On the afternoon of 4/4/11 the double doors between the corridor and the ED suite in the ambulance triage area did not close and latch.

3. On the afternoon of 4/6/11 the entrance doors between the corridor and the surgical intensive care unit did not close and latch and did not resist the passage of smoke. A gap approximately 1/4 " was noted at the meeting edges.

4. On the afternoon of 4/7/11 the ambulatory surgical suite corridor doors did not close, latch or resist the passage of smoke.

Based on observation the hospital did not ensure that vertical separation was maintained.

Findings include:

Plumbing chase

Big gaps between cinderblock walls stairwell MEETH

Dumbwaiter door not latching in SPD

An abandonded vent in the darkroom in the OR site not removed or capped off

Based on observation and staff interview access to exits were not marked by approved, readily visible signs.

Findings are:

1. On the afternoon of 4/4/11 exit signs were not readily visible from all areas of the emergency department (ED) and from treatment room # 2.

2. On the afternoon of 4/4/11 direction of travel from the stairwell providing egress from the kitchen area to discharge at Park Avenue was not clear. Once inside the stair one can travel up the stairs or down. Exit to the public way requires travel up the stairs. No exit sign was provided to direct travel up to the level of discharge. In addition, the stair going down to the basement was not interrupted by a partition, gate or other effective means to prevent travel beyond the level of discharge.

3. On the afternoon of 4/4/11 it was noted that an exit sign was not provided from the clean equipment room (materials management) to the corridor.

Based on observations,record review, and interview during tours of the hospital between 4/4/11 and 4/8/11 the hospital did not ensure that smoke barriers are maintained as required.

Findings include:

1. The smoke barrier doors on the 7 th floor between Wollman / Lachman buildings were noted held open with magnetic hold open devices. The smoke detectors required to ensure that the doors release in the event of a smoke condition were located 12 feet from the door rather than a maximum of 5 feet.

2. Penetrations were noted above the smoke barrier doors adjacent to room 8612.

Based on observations and record review made between 4/4/11and 4/8/11 the hospital did not ensure that hazardous areas are protected as required.

Findings:

1. The materials management storage room was not completely separated. The sheetrock wall did not extend above the deck on all four sides particularly the wall separating this area from the sterilization processing department. Numerous penetrations and incompletely firestopped penetrations were also observed.

2. Observation of the sheetrock wall above the dropped ceiling revealed that Storeroom B and the storage room containing positions equipment, much of which is cushioned with foam padding, were not separated. Storeroom B was only partially sprinklered.

3. Penetrations were noted in the one hour separation in soiled utility room on the 7th floor surgical intensive care unit. The room was not sprinklered.

4. The one hour separation of the rated wall of the basement paint shop were compromised by penetrations.

Based on observation and interview flammable chemicals used by the laboratory are not stored as required.

Findings:

1. On the afternoon of 4/7/11 a closet in the corridor outside the laboratory used to recycle zylene and alcohol lacked one hour separation. The walls of the room did not extend to the deck but only to the dropped ceiling. Approximately 25 gallons of flammable liquids were being recycled and stored in this closet. Confirmed in interview with staff # 14.

2. On the afternoon of 4/7/11 two 10 gallon containers used to collect used zylene and alcohol were noted in the histology lab. No more than one gallon of a flammable liquid is allowed outside a safety cabinet and no more than 2 gallons inside an approved storage cabinet.
NFPA 99 1999 10-7.2.2

Based on observation on the morning of 4/4/11 the hospital did not ensure that exit components were appropriately designed and maintained.

Findings:

1. The rating of exit Stair B doors at the level of discharge was compromised by a gap approximately 1/3 to 1/4 inch at the meeting edges.

2. The gate in stair B installed to prevent travel below the level of discharge was noted hanging off the wall because one of two bolts was missing.

3. The exit door from the kitchen, in the vicinity of the tray line, was noted provided with a prohibited manual pull from the egress side.
NFPA 101 2000 19.2.2.2.4

Dead ends

Based on observation the hospital did not ensure that all exits are readily accessible at all times.

Finding:

The Cafe in the lobby of the 64 th street building restricted the width of the exit corridor. The width of corridor was reduced to 75" on the diagonal.

Based on observation the hospital did not always ensure that two means of egress are provided from rooms greater than 1000 sq. ft. for patient sleeping and 2500 sq. ft for non-sleeping rooms..

Findings:

1. During a tour of the sterile processing department (SPD) on the afternoon of 4/4/11 it was noted that the 2nd exit is from the clean side of the processing is not into a corridor but rather through a heavily congested storage room i.e., a hazardous area, and then back into the decontamination side of the same SPD room. Travel to an exit shall not be through a hazardous area. In addition, travel is through two intervening rooms and the travel distance is greater than 50'.
NFPA 101 2000 18.2.5.5 / 18.2.5.8

2. On the morning of 4/7/11 during a tour of the special care suite on the psychiatric unit it was noted that this sleeping suite was 1472 sq. ft. and had only one exit.

Based on observation not all patient room doors can be opened from the inside without the use of a key.

Finding:

On the morning of 4/7/11 doors to the 8 th floor psychiatric patient sleeping rooms were noted provided with a deadbolt lock not operable from the inside.

Based on record review and staff interview on 4/5/11 and 4/8/1, the hospital did not ensure that all staff members are familiar with fire safety procedures.

Findings:

1. On the morning of 4/5/11 six kitchen staff members were interviewed on fire safety. Five out of six staff members did not know the location of the manual pulls. These included the director and assistant director of nutritional services. Staff members indicated that they would call "5151" in the event of fire.
Some were confused by the blue pull on the wall by the door. This pull is used to open the door and is not a manual pull used to activate the FA system.

2. No documentation was available to show that site specific fire drills in the operating room (OR) suite have been conducted at any time at the 77 th Street and 64 th Street campuses.
NFPA 99 1999 12-4.1.2.10

3. There was no documentation available to show that OR staff were in-serviced on site specific OR fires at the 77 th Street campus.
NFPA 99 1999 12-4.1.2.10

4. Review of the site specific OR fire safety in-service conducted at the 64 th Street campus on 4/6/11 revealed minimal participation by surgeons.
NFPA 99 1999 12-4.1.2.10

5. Review of fire drill records indicate that, except for physicians on the psychiatric unit, physician participation in fire drills is minimal.

Based on record review and interview the hospital did not ensure that all components of the fire alarm (FA) system were maintained in accordance with NFPA 72

Findings:

1. Service reports reveal that when the vendor identified deficiencies the hospital did not always ensure that the deficiency was corrected. Follow up documentation for the following was requested but could not be provided. Examples include but are not limited to:

a. The fire and smoke damper report dated May 16, 2006 stated that 3% of the hospitals dampers failed inspection. This was because dampers were not accessible for testing or were defective.

b. The HVAC fan shutdown report dated July 7-9 2010 showed that approximately 30 devices failed upon activation of the fire alarm system and/or could not be located.

c. A report dated March 24, 2011 for the 64 th Street campus showed that the fire alarm was not activated when the electronic waterflow alarm was tested on the 1st and 2nd floors in Stair C.

d. The backflow valve tamper switch tested on Mar 23, 2011 at the 64 th Street campus actuated only when held down manually.

Note: The hospital was on Fire Watch at both campuses.

2. It could not be determined if all fire safety equipment and components of the FA system that require testing were, in fact, tested because records do not always include an inventory of all devices. There is, for example, no inventory of fire hoses and notification and initiating devices.

3. Based on observations and interview made on the afternoon of 4/8/11 at 3:20 PM during a hospital wide test of the FA system at the 64 th Street campus it was determined that the fire alarm notification system was was not fully functional.

Findings:

a. Two audible / visual notification devises in the PACU located on the 2nd floor did not activate. This observation was confirmed by staff members # 10 and 11.

b. On the sixth floor of the building the overhead announcement that a fire drill was being conducted could not be heard. Audible / visible notification devices did not activated in the area under observation but could be heard in the distance. Confirmed by security staff.

c. The overhead announcement that a fire drill was being conducted could not be heard in the basement.

Based on observation, document review and interview the hospital did not ensure that all the components of the sprinkler system are maintained in accordance with NFPA 25

Findings include but are not limited to:

1. Review of hospital records show that various buildings on the two campuses are > 50 years of age. There was not documentation to show that standard response sprinkler heads, that might be > than 50 years old, were tested within the last ten years. Staff member # 12 stated in interview that the sprinkler heads were tested, however, no documentation could be provided.

2. No documentation was available to show that the 5 year internal inspections for obstructions were conducted on sprinkler piping,, check valves, alarm valves and associated trim.

3. No documentation was available to show that visual inspections of sprinkler heads and visible pipe were conducted. Several overhead sprinkler heads in the materials management room at the 64 th street campus were observed clogged with grease and dust.

4. Review of main drain test results revealed that an hydraulic name plate with residual pressure was not available nor were previous years results available for comparison to determine if there were changes in water pressure or flow.

5. 18" clearance was not provide around sprinkler heads in the plumbing and electrical shops.

Based on observation the hospital did not ensure that the sprinkler system was installed in accordance
with NFPA 13.

Finding:

On the afternoon of 4/4/11 a sprinkler head in the ortho instrumentation area of was observed installed 2" from the wall rather than a minimum of 4".

Based on observations the hospital did not not ensure that all means of egress were continuously maintained to provide full instant use in the event of emergency.

Findings are:

1. On the morning of 4/4/11 the exterior exit passageway from exit B to the public way at 76 th Street was noted obstructed by sheetrock, particle board, joint compound, lumber, containers of joint compound and 2 5 gallon containers of gasoline. In addition, a drain in the exit passageway was clogged and a large pool of water approximately 1" deep was noted.

2. On the afternoon of 4/4/11 the exit passage in the vicinity of the building services store room was noted obstructed by eight 90 gallon transport bins stored along the wall. The transport bins narrowed the with of the passage from six feet wide to three feet wide.

Based on observation the hospital did not ensure that medical gas storage is protected as required.

Finding:

On the afternoon of 4/8/2011 the fire retardant material had fallen off some areas of the Q deck ceiling and steel beams of the manifold room compromising the rating of the room.

Based on record review and interview the hospital failed to ensure that medical gas systems comply with NFPA 99.

Finding is:

Review of medical gas reports on 4/6/11 for both the 77 th street campus and the 64 th street campus, indicated that while both the vendor for the 77 th street campus and the vendor for the 64 th Street campus identified deficiencies there is no documentation to show that corrective action was taken .
This was confirmed in interview with staff member # 12

Based on record review,observation and interview the hospital provides life support equipment but lacks a Type 1 Essential Electrical System (EES).

Findings:

Review of the facility's emergency generator records on 4/7/11 and 4/8/11 indicated that the hospital's generator is not divided into life safety, critical and equipment branches. This was confirmed in interview with Staff # 25.

Cross Refer to K 145

Based on observation not all areas are sprinklered as required.

Findings include:

1. On the afternoon of 4/4/11 the a closet in the support suite adjacent to the administrative suite lacked a sprinkler head.
2. The volunteers work room lacked sprinkler heads.


Based on observation, document review and interview the hospital did not ensure that exit access was arranged so that there were no dead ends greater than 30 feet.

Finding:

On the afternoon of 4/6/11 during a tour of the renovated ICU on the 7 th floor a dead end greater than 30 feet was noted. Travel distance from the end of the corridor to the stair was 60 feet. This was confirmed in interview with staff member # 14. Review of floor plans shows that dead end corridors 60 feet in length exist on the renovated 5th floor CCU, and renovated 8 th and 9 th floor ICUs
NFPA 101 2000 edition 18.2.5.10

Based on observation the hospital did not ensure that combustible liquids are stored in approved cabinets.

Finding:

On the afternoon of 4/8/11 the storage cabinet for flammable liquids in the laboratory at the 64 th Street campus was compromised due to a hole approximately 2" in diameter in its side.

Based on document review and and interview the hospital did not ensure a safe environment in the laboratory.

Finding;

Review of documents revealed that a safety checklist was not available. Interview with laboratory staff indicated that while the hospital employed a laboratory safety office in January 2011 the safety officer has not yet developed a safety checklist.
NFPA 99 1999 10-8.1.3

Based on observation, record review and interview the facility provides general anesthesia, has NFPA 99-1999 defined "Critical Care Areas" (i.e., Operating rooms where NFPA 99 defined "invasive procedures" are performed and patients are connected to line operated patient care-related electrical appliances) and the Essential Electrical System (EES) is not a Type 1 EES in full compliance with NFPA and NFPA 70.

Findings include:

The wiring for items required to be served by the Equipment System was not independent from wiring for items required to be served by the Emergency System and the wiring for items required to be served by the Emergency System - Critical Branch was not separate from the wiring for items required to be served by the Emergency System - Life Safety Branch. Verified in interview with Staff. # 25.

Based on observation the hospital did not ensure that electrical equipment was maintained in accordance with NFPA 70.

Finding:

On the afternoon of 4/7/11 trash was noted stored in the electrical switchgear room. Penetrations were noted in the 2 hour rated walls.