HospitalInspections.org

Based on observations and staff interview, the facility's corridors were not separated by walls with at least two hour fire resistance rating.

The findings include:

On the afternoon of 7/11/2014 observation during a life safety tour of the hospital revealed that the facility's corridors were not separated by walls with a two hour fire resistance rating.

1. On the 11th floor there was a pipe support thread that punctured through the first layer of sheetrock on one of the fire-rated walls.

2. On the 10th floor there were two data wires passing through the wall between the head of the wall joint and the top of the sheetrock on one of the fire-rated walls.

3. On the 8th floor there was a data wire passing through the wall between the head of the wall joint and the top of the sheer on one of the fire-rated walls.

These findings were concurrently verified by Staff #1, the Vice President of Administration.

Based on observation and staff interview, the facility's doors protecting corridor openings were not capable of resisting fire for at least 20 minutes. Specifically, none of the facility's fire-rated door frames had the required fire-rated labels attached to them.

The finding is:

During the survey from 7/9/2014 to 7/15/2014 observation revealed that none of the the facility's fire-rated door frames had the required fire-rated labels attached to them.

This finding was concurrently verified by the Staff #1, the Vice President of Administration.

Based on observations and staff interview, the facility's smoke barriers were not constructed to provide at least a one half hour fire resistance rating in accordance with 8.3.

The findings include:

On the afternoon of 7/11/2014 observation during a life safety tour of the hospital revealed that the facility's smoke barriers were not constructed to provide at least a one half hour fire resistance rating in accordance with 8.3.

1. On the 12th floor the following was found:
a) A partially sealed pipe penetration was found over a smoke barrier door.

b) Within the 12B Post Partum/Neonatal Intensive-Care Unit smoke barrier there was a metal conduit in which the inside of the conduit was not sealed.

These findings were concurrently verified by Staff #1, the Vice President of Administration.

Based of observation and staff interview, the Ambulatory Psychiatric Center extension clinic's emergency exit fire resistance rating of at least one hour was not maintained.

The findings were:

On the morning of 7/14/2014 observation revealed that the Ambulatory Psychiatric Center extension clinic's emergency exit fire resistance rating of at least one hour was not maintained.
Specifically:
1. a) There was an unsealed hole that passed completely through a 6th floor metal fire-rated door.

b) There was a bundle of data wires that passed through the Crime Victims Unit one hour fire-rated wall.

c) There was a bundle of data wires that passed through the ground floor lobby one hour fire-rated wall.

2. The 5th floor entrance door to Psychiatric Services did not self close.

3. While walking the emergency exit stairwell, there were three wooden wedges used as door stoppers for three of the rooms that open into this stairwell.

4. The entrance door to 2nd floor Crime Victims Unit was damaged.

These findings were concurrently verified by Staff #1, the Vice President of Administration.

Based on record review and staff interview, the Ambulatory Psychiatric Center extension clinic's battery back-up emergency lighting was not tested for at least 1½ hour in accordance with 7.9 and 19.2.9.1.

The finding is:

On the morning of 7/14/2014 interview with Staff #2, the Building Superintendent, revealed that this facility's battery back-up emergency lighting was not tested for at least 1½ hour in accordance with 7.9 and 19.2.9.1.

A record review request for the battery backup emergency lighting of this offsite extension clinic confirmed that testing was never performed.

Based on observation and staff interview, the facility's sprinkler system was not maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

The findings include:

1. On the afternoon of 7/9/2014 observation in Room GE25A, the Storage Room, revealed that there were boxes of syringes, etc. stored less then 18 inches from the ceiling sprinkler head.

2. On the afternoon of 7/9/2014 observation in the Emergency Department revealed that a reduced pressure zone valve located in the Mechanical Equipment Room was inaccessible due to Police Line Do Not Cross Signage, Barricades, a wheelchair, etc.

3. On the afternoon of 7/14/2014 observation in the Ambulatory Psychiatric Center extension clinic 3rd floor hallway revealed that a sprinkler head was located approximately one inch from the wall in the vicinity of the Staff Bathroom.

4. On the afternoon of 7/14/2014 observation in the Ambulatory Psychiatric Center extension clinic revealed that a sprinklerhead was not installed in the 3rd. Floor Bathroom.

5. On the afternoon of 7/14/2014 observation in the Ambulatory Psychiatric Center extension clinic revealed that a sprinklerhead was not installed in the 2nd. Floor Bathroom.

These findings were concurrently verified by Staff #1, the Vice President of Administration.

Based on observation and staff interview, the facility's automatic sprinkler systems were not continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

The finding is:

On the morning of 7/9/2014 observation revealed that in the hallway between operating room #16 and #17 there were two painted over ceiling sprinkler heads.

This finding was concurrently verified by Staff #1, the Vice President of Administration.

Based of observation and staff interview, the Ambulatory Psychiatric Center extension clinic's secondary means of egress was not maintained free of all obstructions or impediments in case of fire or other emergency.
The finding is:

On the afternoon of 7/14/2014 observation revealed that the secondary means of egress via the fire escape to an outdoor ground level platform, was obstructed by weeds, piles of garbage and leaves, pieces of metal, and other debris.

This finding was concurrently verified by Staff #1, the Vice President of Administration.

Based on record review and staff interview, the facility did not have master alarm panels located in two separate locations.

The finding is:

On the afternoon of 7/14/2014 during interview with Staff #1, the Vice President of Administration, he stated "During a recent mock survey it was revealed that this hospital has only one medical gas master alarm panel. The facility has submitted a purchase order to have a second installed within the Security Department."

Record review of the purchase order #713521, dated March 13, 2014, confirmed what was stated during the interview. At the close of this federal survey the facility has not yet physically started this project.

Based on record review and staff interview the facility's Type I Essential Electrical System (EES) was not divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. 3.4.2.2.2.

The finding is:

On the afternoon of 7/14/2014 during interview with Staff #1, the Vice President of Administration, he stated "In November 2013 after an affiliated hospital, Beth Israel Medical Center, was found not to have a compliant Type 1 Essential Electrical System, a mock survey was done at this hospital. It revealed that there was certain equipment located on the Life Safety Branch. In response to this, a time limited waiver was submitted to the New York State Bureau of Architectural and Engineering Facility Planning (BAEFP)."

Record review of the time limited waiver, that was signed and dated on 6/10/2014, confirmed what was stated during the interview. At the close of this federal survey the facility has not yet been granted approval from BAEFP.

Based on observation and staff interview the facility's electrical wiring and equipment was not in accordance with NFPA 70, National Electrical Code. 9.1.2. Specifically, two electrical disconnects were inaccessible.

The finding is:

On the afternoon of 7/9/2014 observation in the dirty side of the Central Sterile Services Department revealed that there was large compressor blocking access to an electrical disconnect for a Amsco 444 Instrument Washer and to an electrical disconnect for a Steris Reliance Washer/Disinfector.
This finding was concurrently verified by Staff #1, the Vice President of Administration.

Based on observations and staff interview, the facility's corridors were not separated by walls with at least two hour fire resistance rating.

The findings include:

On the afternoon of 7/11/2014 observation during a life safety tour of the hospital revealed that the facility's corridors were not separated by walls with a two hour fire resistance rating.

1. On the 11th floor there was a pipe support thread that punctured through the first layer of sheetrock on one of the fire-rated walls.

2. On the 10th floor there were two data wires passing through the wall between the head of the wall joint and the top of the sheetrock on one of the fire-rated walls.

3. On the 8th floor there was a data wire passing through the wall between the head of the wall joint and the top of the sheer on one of the fire-rated walls.

These findings were concurrently verified by Staff #1, the Vice President of Administration.

Based on observation and staff interview, the facility's doors protecting corridor openings were not capable of resisting fire for at least 20 minutes. Specifically, none of the facility's fire-rated door frames had the required fire-rated labels attached to them.

The finding is:

During the survey from 7/9/2014 to 7/15/2014 observation revealed that none of the the facility's fire-rated door frames had the required fire-rated labels attached to them.

This finding was concurrently verified by the Staff #1, the Vice President of Administration.

Based on observations and staff interview, the facility's smoke barriers were not constructed to provide at least a one half hour fire resistance rating in accordance with 8.3.

The findings include:

On the afternoon of 7/11/2014 observation during a life safety tour of the hospital revealed that the facility's smoke barriers were not constructed to provide at least a one half hour fire resistance rating in accordance with 8.3.

1. On the 12th floor the following was found:
a) A partially sealed pipe penetration was found over a smoke barrier door.

b) Within the 12B Post Partum/Neonatal Intensive-Care Unit smoke barrier there was a metal conduit in which the inside of the conduit was not sealed.

These findings were concurrently verified by Staff #1, the Vice President of Administration.

Based of observation and staff interview, the Ambulatory Psychiatric Center extension clinic's emergency exit fire resistance rating of at least one hour was not maintained.

The findings were:

On the morning of 7/14/2014 observation revealed that the Ambulatory Psychiatric Center extension clinic's emergency exit fire resistance rating of at least one hour was not maintained.
Specifically:
1. a) There was an unsealed hole that passed completely through a 6th floor metal fire-rated door.

b) There was a bundle of data wires that passed through the Crime Victims Unit one hour fire-rated wall.

c) There was a bundle of data wires that passed through the ground floor lobby one hour fire-rated wall.

2. The 5th floor entrance door to Psychiatric Services did not self close.

3. While walking the emergency exit stairwell, there were three wooden wedges used as door stoppers for three of the rooms that open into this stairwell.

4. The entrance door to 2nd floor Crime Victims Unit was damaged.

These findings were concurrently verified by Staff #1, the Vice President of Administration.

Based on record review and staff interview, the Ambulatory Psychiatric Center extension clinic's battery back-up emergency lighting was not tested for at least 1½ hour in accordance with 7.9 and 19.2.9.1.

The finding is:

On the morning of 7/14/2014 interview with Staff #2, the Building Superintendent, revealed that this facility's battery back-up emergency lighting was not tested for at least 1½ hour in accordance with 7.9 and 19.2.9.1.

A record review request for the battery backup emergency lighting of this offsite extension clinic confirmed that testing was never performed.

Based on observation and staff interview, the facility's sprinkler system was not maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

The findings include:

1. On the afternoon of 7/9/2014 observation in Room GE25A, the Storage Room, revealed that there were boxes of syringes, etc. stored less then 18 inches from the ceiling sprinkler head.

2. On the afternoon of 7/9/2014 observation in the Emergency Department revealed that a reduced pressure zone valve located in the Mechanical Equipment Room was inaccessible due to Police Line Do Not Cross Signage, Barricades, a wheelchair, etc.

3. On the afternoon of 7/14/2014 observation in the Ambulatory Psychiatric Center extension clinic 3rd floor hallway revealed that a sprinkler head was located approximately one inch from the wall in the vicinity of the Staff Bathroom.

4. On the afternoon of 7/14/2014 observation in the Ambulatory Psychiatric Center extension clinic revealed that a sprinklerhead was not installed in the 3rd. Floor Bathroom.

5. On the afternoon of 7/14/2014 observation in the Ambulatory Psychiatric Center extension clinic revealed that a sprinklerhead was not installed in the 2nd. Floor Bathroom.

These findings were concurrently verified by Staff #1, the Vice President of Administration.

Based on observation and staff interview, the facility's automatic sprinkler systems were not continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5.

The finding is:

On the morning of 7/9/2014 observation revealed that in the hallway between operating room #16 and #17 there were two painted over ceiling sprinkler heads.

This finding was concurrently verified by Staff #1, the Vice President of Administration.

Based of observation and staff interview, the Ambulatory Psychiatric Center extension clinic's secondary means of egress was not maintained free of all obstructions or impediments in case of fire or other emergency.
The finding is:

On the afternoon of 7/14/2014 observation revealed that the secondary means of egress via the fire escape to an outdoor ground level platform, was obstructed by weeds, piles of garbage and leaves, pieces of metal, and other debris.

This finding was concurrently verified by Staff #1, the Vice President of Administration.

Based on record review and staff interview, the facility did not have master alarm panels located in two separate locations.

The finding is:

On the afternoon of 7/14/2014 during interview with Staff #1, the Vice President of Administration, he stated "During a recent mock survey it was revealed that this hospital has only one medical gas master alarm panel. The facility has submitted a purchase order to have a second installed within the Security Department."

Record review of the purchase order #713521, dated March 13, 2014, confirmed what was stated during the interview. At the close of this federal survey the facility has not yet physically started this project.

Based on record review and staff interview the facility's Type I Essential Electrical System (EES) was not divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. 3.4.2.2.2.

The finding is:

On the afternoon of 7/14/2014 during interview with Staff #1, the Vice President of Administration, he stated "In November 2013 after an affiliated hospital, Beth Israel Medical Center, was found not to have a compliant Type 1 Essential Electrical System, a mock survey was done at this hospital. It revealed that there was certain equipment located on the Life Safety Branch. In response to this, a time limited waiver was submitted to the New York State Bureau of Architectural and Engineering Facility Planning (BAEFP)."

Record review of the time limited waiver, that was signed and dated on 6/10/2014, confirmed what was stated during the interview. At the close of this federal survey the facility has not yet been granted approval from BAEFP.

Based on observation and staff interview the facility's electrical wiring and equipment was not in accordance with NFPA 70, National Electrical Code. 9.1.2. Specifically, two electrical disconnects were inaccessible.

The finding is:

On the afternoon of 7/9/2014 observation in the dirty side of the Central Sterile Services Department revealed that there was large compressor blocking access to an electrical disconnect for a Amsco 444 Instrument Washer and to an electrical disconnect for a Steris Reliance Washer/Disinfector.
This finding was concurrently verified by Staff #1, the Vice President of Administration.