HospitalInspections.org

Based on documentation review and staff interview, required emergency lighting system was not tested for duration mandated by the code.

The findings are:

Review of the records on testing of the emergency lighting systems revealed that the testing duration was less than 90 minutes. This was identified in Building 59 and Building 60. Examples are:

1. Building 59: Tunnel/Food Tunnel 10:52 AM - 11:59 AM.
2. Building 59: Outside Enclosure/Emergency Generator 10:40 AM -11:48 AM.
3. Building 60: WB40/Transformer Room 10:25 AM -10:56 AM.

In an interview conducted on 11/1/2019 at approximately 2:00 PM, the Director Administration, Staff Y, acknowledged the findings.

Based on document review and staff interview, it was identified that fire drills were conducted at the same time on night and evening shift in the facility.

The findings are:

During the documentation review of the fire drills, summary sheet of fire drills revealed that drills were conducted at the same time on the night and evening shift in the facility. Examples are:

1. Building 58: 1/24/2019 at 6:47 AM & 2/11/2019 at 6:57 AM - Night Shift.
2. Building 59: 7/29/2019 at 6:53 AM & 08/25/2019 at 6:57 AM - Night Shift.
3. Building 59: 1/15/2019 at 5:03 PM & 2/19/2019 at 5:16 PM - Evening Shift.


During an interview conducted on 11/1/2019 at approximately 2:00 PM, the Chief of Safety and Security, Staff Z, stated he had acknowledged the issue before the documents were reviewed.

2012 NFPA 101: 19.7.1, 19.7.1.6
10NYCRR 711.2(a)(1)

Based on staff interview and document review, the hospital did not have records of testing the Hospital -grade receptacles and receptacles not listed as hospital-grade at the bed location as required by NFPA 99.

Finding includes:

During review of the hospital's maintenance records and interview of the hospital's Director of Administration, Staff Y, on 10/31/2019 at 1:30 PM, it was revealed that the hospital did not conduct testing for the hospital-grade or the non hospital grade receptacles.
The hospital's Director of Administration indicated that the hospital didn't have any record for and did not tested the hospital-grade receptacles or the receptacles not listed as hospital grade at the bed locations.