HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure that vision panels installed on the smoke barrier door are fire rated window assemblies in approved frames.

Findings include:

During the tour of the two psychiatric inpatient units (3rd and 5th floors of the Hemmet Building) on 10/24/16 between 10 AM and 12:00 noon, the surveyors noted that the vision panels on the two smoke barrier doors in each of the units were covered over with a plexi glass panel approximately 18 inches X 18 inches. This plexi glass panel was observed to be non-fire rated, thereby compromising the fire rating of the door assembly.

Upon interview, on 10/24/16 at approximately 3:15 PM, Staff M, Director of Facilities, acknowledged these findings

Based on observation and staff interview, the facility did not ensure that smoke barrier double doors are maintained to provide the required fire -resistive rating, and resist the passage of smoke from one compartment to the other,

Findings include:

During the tour of the facility on 10/18/16 through 10/25/16, the following observations were made:

The door frame of the fire barrier in the emergency department by the ambulance bay, did not have fire-rating label on it, thereby compromising the fire-rating of the door assembly. Additionally, a gap of approximately 3/4 inch, was noted between the leaves upon closure, thereby not resisting the passage of smoke.

The fire resistant rating label on the door frame of the fire barrier 503, in the in-patient Psychiatric unit, 5th floor of Hemmet building, was painted over.

The fire resistant rating label on the door frame of the fire barrier, in the male side of the in-patient Psychiatric unit, 3rd floor of Hemmet building, was painted over.


These findings were acknowledged by Staff M, Director of Facilities on 10/25/16.

Based on observation and staff interview, the facility failed to ensure that hazardous areas are adequately separated from adjacent areas, with intact walls and self-closing doors.
Specific reference is made to the storage area in the Respiratory Department.

Findings include:

During the tour of the Respiratory Department on 10/23/16 at approximately 2:00 PM, the surveyors noted that clean respiratory supplies were stored in a room that was not fully enclosed and did not have a self-closing door. The building is not equipped with sprinkler system.

It was noted that the storage area had approximately 30 card boxes containing heater element for respirators, stacked on the floor. In addition, two big plastic bins containing teaching supplies, were also noted on the floor.

Upon interview, on 10/23/16 at approximately 2:15 PM, Staff M, Director of Facilities, acknowledged these findings.

Based on observation and interview, the facility failed to ensure that exit access is so arranged that exits are readily accessible at all times.

Findings:

On 10/18/16 at approximately 10:00 AM, the surveyors observed a privacy curtain installed on tracks across the exit corridor, towards the back end of the Emergency Room, leading to the Ambulance Bay.
Interview of Staff K, Chief Operating Officer, on 10/18/16 at approximately 10:15 AM, revealed that the corridor was used to resuscitate patients arriving by ambulance, and that area would be cordoned off by a cubicle curtain when in use.
It was determined that this arrangement caused the blockage of the exit access when the space was in use for patient care.


During the tour of the Respiratory Department, on 10/24/16 at approximately 2:00 PM, it was noted that a corridor leading to exit access was being obstructed by clean supply storage on big metal carts, and a copier machine.

This finding was acknowledged by Staff M, Director of Facilities, on 10/24/16 at approximately 3:15 PM.

Based on observation and interview, it was determined the facility failed to ensure that sprinkler coverage was provided in all required areas.


Findings include:

During the tour of the facility on 10/18/16 through 10/24/16, the following observations were made:

The Machine Room on the 4th floor of the main building, lacked sprinkler heads connected to the fire alarm system.

The telecommunication closet, located on the 5th floor of the main building did not have sprinkler system. installed.


The electrical closet (Room #310) located on the 3rd floor of the Hemmet building, inpatient Psychiatric Unit, did not have sprinkler heads installed on the ceiling.


A sprinkler head in the Clean Utility Room of the Pediatric Emergency Department, was recessed approximately 2 inches above the tiles, which will effect the proper spray pattern in case of fire.

The telecommunication closet located on the 4th floor of the Tower Building, was noted to have an upright sprinkler head installed at a distance of an inch from a junction box. This arrangement will affect the intended spray pattern, in case of fire.

The findings were acknowledged by Staff M, Director of Facilities on 10/24/16 at approximately 3:15 PM.

Based on observation and staff interview, it was determined the facility did not ensure that medical gas storage area comply with NFPA 99.

Findings include:

During the tour of the Respiratory Department on 10/24/16 at approximately 2:30 PM, the surveyors noted that the facility stored 18 full oxygen "E" tanks in the corridor, outside the Decontamination Room.
It was determined that the 18"E" Oxygen cylinders constitute more than 3000 cubic feet of oxygen, and therefore, are required to be stored in 1 hour fire-rated enclosure with mechanical ventilation, as required by NFPA 99.

This finding was acknowledged by Staff M, Director of Facilities, during interview on 10/24/16 at approximately 3:15 PM.

Based on observation, documentation review and interview, it was determined the facility was not provided with a Type 1 Essential Electrical System that was divided into separate Critical Branch, Life Safety Branch and Equipment Systems; in accordance with NFPA 99. This was noted on all the floors of the main building and Hemmet building.

Findings:

Examples include but are not limited to the following:

On 10/24/16 at approximately 11:00 AM, review of the Emergency Electrical Power Panel Directory for Panel "5AC1," on the 5th Floor of Hemmet building, revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Corridor Lights) and Normal Equipment System-(e.g., Receptacles).


On 10/24/16 at approximately 3:00 PM, the surveyors inspected the electrical panel in the kitchen and observed that there was no distribution of power into life safety, critical and equipment branches. The Emergency Electrical panel did not specify the branch/es of the electrical system i.e. Life Safety, Critical or Equipment served by this panel. This panel did not have directory for the circuit breakers.


These findings were acknowledged by Staff M, Director of facilities, on 10/24/16, at approximately 3:15 PM.

Based on observation and interview, the facility failed to ensure that all Emergency Power Panel Directories were provided with Panel Directories. This was noted in Tower building and in the Hemmet building

Findings:

During the tour of facility, 10/18/16 through 10/25/16, the following missing Emergency Power Panel Directories were noted, including but not limited to:

a) The 3rd Floor East Tower Building Electrical Room - Panel "LSLP3."

b) The 3rd Floor East Electrical Room - Panel "CRP3A."

c) The Emergency Electrical Panel in the kitchen - 2NI8C.
These findings were acknowledged by Staff M, Director of Facilities, on 10/25/16 at approximately 3:30 PM.

Based on observation and staff interview, the facility failed to ensure that vision panels installed on the smoke barrier door are fire rated window assemblies in approved frames.

Findings include:

During the tour of the two psychiatric inpatient units (3rd and 5th floors of the Hemmet Building) on 10/24/16 between 10 AM and 12:00 noon, the surveyors noted that the vision panels on the two smoke barrier doors in each of the units were covered over with a plexi glass panel approximately 18 inches X 18 inches. This plexi glass panel was observed to be non-fire rated, thereby compromising the fire rating of the door assembly.

Upon interview, on 10/24/16 at approximately 3:15 PM, Staff M, Director of Facilities, acknowledged these findings

Based on observation and staff interview, the facility did not ensure that smoke barrier double doors are maintained to provide the required fire -resistive rating, and resist the passage of smoke from one compartment to the other,

Findings include:

During the tour of the facility on 10/18/16 through 10/25/16, the following observations were made:

The door frame of the fire barrier in the emergency department by the ambulance bay, did not have fire-rating label on it, thereby compromising the fire-rating of the door assembly. Additionally, a gap of approximately 3/4 inch, was noted between the leaves upon closure, thereby not resisting the passage of smoke.

The fire resistant rating label on the door frame of the fire barrier 503, in the in-patient Psychiatric unit, 5th floor of Hemmet building, was painted over.

The fire resistant rating label on the door frame of the fire barrier, in the male side of the in-patient Psychiatric unit, 3rd floor of Hemmet building, was painted over.


These findings were acknowledged by Staff M, Director of Facilities on 10/25/16.

Based on observation and staff interview, the facility failed to ensure that hazardous areas are adequately separated from adjacent areas, with intact walls and self-closing doors.
Specific reference is made to the storage area in the Respiratory Department.

Findings include:

During the tour of the Respiratory Department on 10/23/16 at approximately 2:00 PM, the surveyors noted that clean respiratory supplies were stored in a room that was not fully enclosed and did not have a self-closing door. The building is not equipped with sprinkler system.

It was noted that the storage area had approximately 30 card boxes containing heater element for respirators, stacked on the floor. In addition, two big plastic bins containing teaching supplies, were also noted on the floor.

Upon interview, on 10/23/16 at approximately 2:15 PM, Staff M, Director of Facilities, acknowledged these findings.

Based on observation and interview, the facility failed to ensure that exit access is so arranged that exits are readily accessible at all times.

Findings:

On 10/18/16 at approximately 10:00 AM, the surveyors observed a privacy curtain installed on tracks across the exit corridor, towards the back end of the Emergency Room, leading to the Ambulance Bay.
Interview of Staff K, Chief Operating Officer, on 10/18/16 at approximately 10:15 AM, revealed that the corridor was used to resuscitate patients arriving by ambulance, and that area would be cordoned off by a cubicle curtain when in use.
It was determined that this arrangement caused the blockage of the exit access when the space was in use for patient care.


During the tour of the Respiratory Department, on 10/24/16 at approximately 2:00 PM, it was noted that a corridor leading to exit access was being obstructed by clean supply storage on big metal carts, and a copier machine.

This finding was acknowledged by Staff M, Director of Facilities, on 10/24/16 at approximately 3:15 PM.

Based on observation and interview, it was determined the facility failed to ensure that sprinkler coverage was provided in all required areas.


Findings include:

During the tour of the facility on 10/18/16 through 10/24/16, the following observations were made:

The Machine Room on the 4th floor of the main building, lacked sprinkler heads connected to the fire alarm system.

The telecommunication closet, located on the 5th floor of the main building did not have sprinkler system. installed.


The electrical closet (Room #310) located on the 3rd floor of the Hemmet building, inpatient Psychiatric Unit, did not have sprinkler heads installed on the ceiling.


A sprinkler head in the Clean Utility Room of the Pediatric Emergency Department, was recessed approximately 2 inches above the tiles, which will effect the proper spray pattern in case of fire.

The telecommunication closet located on the 4th floor of the Tower Building, was noted to have an upright sprinkler head installed at a distance of an inch from a junction box. This arrangement will affect the intended spray pattern, in case of fire.

The findings were acknowledged by Staff M, Director of Facilities on 10/24/16 at approximately 3:15 PM.

Based on observation and staff interview, it was determined the facility did not ensure that medical gas storage area comply with NFPA 99.

Findings include:

During the tour of the Respiratory Department on 10/24/16 at approximately 2:30 PM, the surveyors noted that the facility stored 18 full oxygen "E" tanks in the corridor, outside the Decontamination Room.
It was determined that the 18"E" Oxygen cylinders constitute more than 3000 cubic feet of oxygen, and therefore, are required to be stored in 1 hour fire-rated enclosure with mechanical ventilation, as required by NFPA 99.

This finding was acknowledged by Staff M, Director of Facilities, during interview on 10/24/16 at approximately 3:15 PM.

Based on observation, documentation review and interview, it was determined the facility was not provided with a Type 1 Essential Electrical System that was divided into separate Critical Branch, Life Safety Branch and Equipment Systems; in accordance with NFPA 99. This was noted on all the floors of the main building and Hemmet building.

Findings:

Examples include but are not limited to the following:

On 10/24/16 at approximately 11:00 AM, review of the Emergency Electrical Power Panel Directory for Panel "5AC1," on the 5th Floor of Hemmet building, revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Corridor Lights) and Normal Equipment System-(e.g., Receptacles).


On 10/24/16 at approximately 3:00 PM, the surveyors inspected the electrical panel in the kitchen and observed that there was no distribution of power into life safety, critical and equipment branches. The Emergency Electrical panel did not specify the branch/es of the electrical system i.e. Life Safety, Critical or Equipment served by this panel. This panel did not have directory for the circuit breakers.


These findings were acknowledged by Staff M, Director of facilities, on 10/24/16, at approximately 3:15 PM.

Based on observation and interview, the facility failed to ensure that all Emergency Power Panel Directories were provided with Panel Directories. This was noted in Tower building and in the Hemmet building

Findings:

During the tour of facility, 10/18/16 through 10/25/16, the following missing Emergency Power Panel Directories were noted, including but not limited to:

a) The 3rd Floor East Tower Building Electrical Room - Panel "LSLP3."

b) The 3rd Floor East Electrical Room - Panel "CRP3A."

c) The Emergency Electrical Panel in the kitchen - 2NI8C.
These findings were acknowledged by Staff M, Director of Facilities, on 10/25/16 at approximately 3:30 PM.