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Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that one open use area on the eighth floor of the J Building was protected in accordance with 18.3.6.1. This could affect all individuals utilizing the services of this smoke compartment. The hospital's census was 988 patients.

Findings include:

Tour was conducted in the J Building from 9:00 AM until 4:30 PM on 4/22/10 with staff members GGGG, WWWW, EEEE, and FFFF. During tour of the eighth floor a waiting area was observed at the end of the corridor. This area was open to the corridor, was fully sprinklered, but lacked smoke detection. This finding was confirmed by staff EEEE during the tour.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that two open use areas were protected in accordance with NFPA 19.3.6.1. This could affect all individuals utilizing the services of the affected smoke compartments. The hospital's census was 988 patients.

Findings include:

Tour was conducted in Building M from 9:00 AM until 12:00 PM on 4/21/10 with staff members EEEE, WW, FFFF, and A6. During tour the third floor play area was observed to have sliding wooden doors to the corridor that could not be latched when closed. The room was fully sprinklered but lacked smoke detection. This finding was confirmed with staff EEEE during the tour.

Tour was conducted in Building G from 1:00 PM until 5:00 PM on 4/20/10 with staff members EEEE, HHHH, FFFF, WW, and GGGG. During tour the family lounge G5-123 was observed to have glass doors to the corridor that could not be latched when closed. The room was fully sprinklered but lacked smoke detection. This finding was confirmed with staff EEEE during the tour.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that one hazardous area on the fifth floor of the J Building was protected by the required 3/4 hour rated door. This could affect all individuals utilizing the services in this smoke compartment. The hospital's census was 988 patients.

Findings include:

Tour was conducted of the J Building from 9:00 AM until 4:30 PM on 4/22/10 with staff members GGGG, WWWW, EEEE, and FFFF. During tour of the fifth floor it was observed that soiled utility room J54-321 had a door that latched securely into the door frame and was on a self-closer; however, the door lacked the required 3/4 hour fire resistance rating. This finding was confirmed by staff EEEE during the tour.

Based on facility observation and staff interview and verification, the facility failed to ensure that exit access was arranged so that exits were readily available at all times. One exit in Building S was affected. The hospital had a capacity of 1214 certified beds with a census of 988 patients at the time of the survey.

Findings include:

On 04/26/10 between the hours of 7:30 AM and 5:00 P.M. a tour of the S Building was completed with Staff EEEE and Staff FFFF. On the first floor at the outpatient laboratory area, an exit corridor was followed to determine the point of exit discharge. The exit door was numbered S-15 exit and was adjacent to S1-03, a pediatric area. An attempt to open the door failed when pressure was applied. A key swipe was noted near the exit door. Staff EEEE verified that the exit door was not to require special unlocking maneuvers and was designated as an exit for the general public to utilize.

Based on observations and staff interviews, the facility failed to ensure one set of delayed egress exit access doors on the lower level were readily accessible in accordance with section 7.1 and 19.2.1. This could affect all staff and visitors in this area. The hospital's census was 988 patients.

Findings include:

A tour was conducted on 04/27/10 between 9:53 AM and 11:50 AM with Staff IIII , Staff EEE and Staff DDD. During this tour, an exit access located by the dock was observed with two leaves of doors that were on a magnetic locking device. The sign on the doors stated PUSH UNTIL ALARMS SOUNDS, DOOR CAN BE OPENED IN 15 SECONDS. These doors were tested three times by the surveyor, and Staff DDD and Staff EEE. The alarm did not sound, the doors failed to open with pushing pressure, and failed to emit an audible alarm in accordance with the code section 7.1 (NFPA 101, 2000 Code). This was verified with both staff (Staff DDD and EEE) at the time of the testing.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that one of three sliding horizontal fire doors in the Q Building was capable of closing in the event of fire. The hospital's census was 988 patients.

Findings include:

Tour of the Q Building was conducted on 4/21/10 from 1:00 PM until 4:30 PM with staff JJJJ, EEEE, and LLLL. At approximately 4:15 PM the three McKeon sliding horizontal fire doors separating the Q Building from the J Building were observed. The door located adjacent to the chapel was observed with a large, heavy riding-type floor scrubber parked unattended in front of the fire door. Staff present on tour needed to mount the scrubber, determine how to start the machine, and drive it out of the way of the McKeon door. It was confirmed with staff present during the tour that this heavy machine would have prevented the closing of the fire door if a fire had occurred.

Based on facility observation and staff interview and verification, the facility failed to ensure that a horizontal door used as a fire door closed properly. One door ( T1-51) was affected. The hospital had a capacity of 1214 certified beds with a census of 988 patients at the time of the survey

Findings include:

On 04/26/10 between the hours of 7:30 AM and 5:00 P.M. a tour of the S Building was completed with Staff EEEE and Staff FFFF. At 4:08 p.m., on the first floor, a fire shutter was observed to be in place between the S building and the T building. Staff EEEE was asked to provide demonstration the door could function without problem. An attempt to activate the fire shutter by Staff EEEE was initiated but the door failed to close. Staff EEEE verified the fire shutter did not operate correctly and that repairs would be made immediately. Staff EEEE stated the facility's fire watch plan would be immediately implemented while repair took place.

On 04/27/10 at 10:15 A.M., Staff A8 verified the fire shutter was repaired. Staff A8 demonstrated the door operated correctly and closed securely. Review of preventative maintenance records revealed the fire shutter had been tested annually and on 09/14/09.

Based on staff interviews, and observations, the facility failed to ensure 3 of 4 exit discharges were equipped with lighting fixtures that would prevent the discharge areas from being in darkness in the event that the lighting fixture (bulb) would fail, in accordance with the code at 7.8. This could affect all patients, staff, and visitors in this facility. The hospital's census was 988 patients.

Findings include:

A tour was conducted on 04/27/10 between 9:53 AM and 11:50 AM with Staff IIII, Staff EEE and Staff DDD. The following exits were observed with a single light fixture that contained one bulb: outside Stair E1 at 90th Street and Carnegie Street, outside Stair E2 on Carnegie Street by the skywalk, and outside Stair E4 on 90th Street on the west side of the building. There were no additional light fixtures observed in these areas. These light fixture bulbs were verified by the staff accompanying the surveyor on tour.

Based on observations and staff interviews, the facility failed to insure the fire alarm system is installed in accordance with NFPA 70 National Electrical Code and NFPA 72, 9.6.1.4. This involved one smoke detector in the building on the first floor and could affect all staff and visitors in that building. The hospital's census was 988 patients.

Findings include:

A tour was conducted in this building on 04/28/10 between 9:42 AM and 11:30 AM with Staff JJJJ, Staff EEE, and Staff HHH. The main fire panel in the first floor lobby was observed with a system trouble light. When questioned as to why the panel had a system trouble light, Staff IIII was notified by facility staff, who then notified Staff III to explain this to the surveyor. Staff III stated a new smoke detector had been installed approximately 1 to 2 months ago in the MRI unit; however, had not been fully interconnected into the fire alarm system, resulting in a system trouble light on the main fire panel. Staff IIII stated the outside contractor would be contacted to finish the work. On 04/30/10 at 11:30 AM, Staff IIII stated the smoke detector is now connected into the fire alarm system.

Based on observations and staff interviews, the facility failed to maintain sprinkler heads and escheon rings on the first floor of the E building. This involved multiple areas of this floor and could affect all the patients in the emergency room and intensive care overflow area (12 beds), along with visitors, and staff. The code at NFPA 25, 9.7.5. The hospital's census was 988 patients.


Findings include:


A tour was conducted on 04/27/10 between 9:53 AM and 11:50 AM with Staff IIII , Staff EEE and Staff DDD. During this tour, on the first floor, dirty, heavily coated sprinkler heads or missing escheon rings were observed in the following areas:

In the ICU spill over unit rooms the sprinkler heads were observed dirty: #12, #10, #9, #8, #5, #4, #2, #1 and by the ambulance exit.
Escheon rings were missing in the ICU spill over unit in the following areas: by room E1-347, two by the elevator and hall dock area, by the coumadin clinic E1-225, in the Coumadin work room and at the entrance at E-13.

In the emergency department (ED), the following sprinkler heads were dusty/dirty:
Three sprinkler heads at the entrance into the unit, three in security office, outside security, behind the ED registration desk, by E1-147, two inside the ambulance entrance, by E1-126, outside E1-101, Room #16, and #18 additional sprinkler heads in the nurses' station and surrounding hallway.

In the E-17 unit dirty sprinkler heads were observed at the nurses' stations, in the conference room, and in the hall by room #2. An escheon ring was missing in EB-20.

In the observation area dirty sprinkler heads were observed outside beds #13, #10, #9 and at the nurses' station, in room #2.

These sprinkler heads were verified with Staff IIII on tour who confirmed the heads were in need of cleaning or needing replacement of escheon rings.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that medical gases were stored according to NFPA 99 in the surgery exit hallway on the fourth floor of the J Building. This could affect all individuals in this smoke compartment. The hospital's census was 988 patients.

Findings include:

Tour was conducted in the J Building from 9:00 AM until 4:30 PM on 4/22/10 with staff members GGGG, WWWW, EEEE, and FFFF. During tour of the fourth floor, it was noted that medical gases exceeding 300 cubic feet were stored in the surgery exit corridor. The medical gases observed were: one M tank of compressed air, one H tank of compressed air; four M tanks of argon; one H tank of argon; four D tanks of helium; and four M tanks of nitrous oxide. It was confirmed by staff EEEE during the tour that these medical gases should not be stored in the open exit corridor.

Based on observations and staff interviews, the facility failed to ensure two oxygen cylinders were secured and protected in accordance with NFPA 99, 4-3.1.1.2. This affected patients in the Intensive Care spill over unit and in the emergency room, as well as all visitors, and staff on the first floor of the E building. The hospital census was 988 patients.

Findings include:

A tour was conducted on 04/27/10 between 9:53 AM and 11:50 AM with Staff DDD. The respiratory therapy room of that unit was observed with 6 E-size oxygen tanks in a rack. Near the rack, two E-tanks of oxygen were observed lying unattended on the floor. One of the two tanks contained approximately a half tank of oxygen. This was verified with Staff DDD at that time.

Based on facility observation, review of facility information and staff interview and verification, the facility failed to ensure that relative humidity was maintained equal to or greater than 35% in anesthetizing locations. The facility had 89 operating rooms located on the main campus of the facility. Two of six buildings that housed operating rooms (Buildings H and G) were affected. Building H contained 13 operating rooms. Building G contained 11 operating rooms. The hospital had a capacity of 1214 certified beds with a census of 988 patients at the time of the survey.

Findings include:

1. On 04/20/10 between 1:30 PM and 4:00 PM during tour, the monitoring location for the hospital's operating rooms humidity levels was observed with staff IIII. Staff XX and Staff A5 were present in the monitoring location. Staff A5 was asked to provide documented humidity levels for the facility's operating rooms. Staff A5 indicated that all the operating rooms humidity levels were electronically monitored and to print the information would require too many pages. Staff A5 provided a sample of one operating room located in the H building. The humidity level for the room was noted to have a high and low reading. The low was 12 percent with the high reading being 20 percent.

The staff (Staff XX and A5) indicated the electronic monitoring involved three systems. Staff XX and Staff A5 indicated that it may not be possible to obtain readings for some operating rooms. The staff was asked to provide 3 days of information, for the H building with the random dates chosen as 02/03, 02/04, and 02/05/10.

On 04/21/10, the information was provided. Review of the humidity levels for the 13 operating rooms in Building H revealed 13 of 13 operating rooms did not reach 35 percent on the dates chosen for review. All humidity levels were noted to be under 28 percent.

Staff XX and Staff A5 could not address what the desired level of humidity was for the facility's operating rooms. Review of the facility policy for environmental control revealed the surgical services locations were to have humidity levels maintained between 30 and 60 percent for ideal conditions related to health and safety.

On 04/23/10 at 10:30 A.M. interview of Staff XX revealed that operating rooms were not notified if humidity levels were too low. Staff XX stated that only when humidity levels become too high were the operating room staff notified.

On 04/28/10 at 10:25 A.M. Staff A5 obtained humidity levels for 13 operating rooms in Building H. Thirteen of 13 operating rooms had humidity levels below 35 percent. The ranges of the humidity levels for the 13 operating rooms were 19.69 percent to 30.03 percent. Humidity levels were also reviewed for 11 operating rooms located in Building G. Eleven of 11 operating rooms in Building G did not have humidity levels of 35 percent of greater. The ranges of humidity levels for the 11 operating rooms were 22.12 percent to 25.85 percent.

Based on facility observation, review of facility policy and staff interview and verification, the facility failed to ensure that relative humidity was maintained equal to or greater than 35% in anesthetizing locations. The facility had 89 operating rooms located on the main campus of the facility. Building E contained 25 operating rooms. Two of 25 rooms (Rooms #16 and #22) was affected. The hospital had a capacity of 1214 certified beds with a census of 988 patients at the time of the survey.

Findings include:

1. On 04/23/10 at 10:35 AM, Staff XX was asked to provided relative humidity levels for two operating rooms in Building E, operating rooms #16 and #22. Staff XX was in the monitor location where the facility's operating room's humidity readings were electronically monitored. According to Staff XX, while all the operating room's humidity levels were electronically monitored the systems utilized by the facility maintained data for limited intervals.

The humidity level for room #16 at that time was noted to be 18.8 percent. No reading could be obtained for operating room #22.

On 04/28/10 at 10:15 A.M. Staff A5, was asked to provide the most current humidity levels for the same two operating rooms. Operating room #16 had a humidity level of 19.4 percent and operating room #22 had a humidity level of 26.4 percent. Staff A5 verified the set percent for the room was 45 percent.

Review of the facility policy for environmental control revealed the surgical services locations were to have humidity levels maintained between 30 and 60 percent for ideal conditions related to health and safety.



03245

Doors shall be operable with not more than one releasing operation. 39.2.2.2.1, 7.2.1.5.4.

This requirement is NOT MET as evidenced by:

Based on observation and interview, it was determined that the facility failed to ensure that two of two sleeping rooms could be opened with not more than one releasing operation. The hospital's census was 988 patients.

Findings include:

Tour was conducted on 4/26/10 from 12:45 PM until 1:15 PM with staff JJJJ, staff MMMM, and individual YYYY. It was observed that the two patient sleeping room doors had handles with a device for latching the doors into the door frame. The doors also had deadbolts located approximately eight inches above the handles. If the deadbolts were secured, this would require any individual in the rooms to use two hand motions to release both locks before exiting the rooms. This finding was confirmed by staff JJJJ and individual YYYY during the tour.

Based on staff interview, review of product information and staff interview and verification, the facility failed to ensure that requirements addressed in National Fire Protections Association (NFPA) 1999 Edition, Chapter 12, Hospital Requirements, 12-4.1.2.2 (b) Germicides, was met. The requirement states that liquid germicides used in anesthetizing locations whenever the use of cautery or electrosurgery is contemplated, shall be nonflammable. Two of 25 operating rooms in the E Building (Rooms #16 and #22) were affected. The hospital had a capacity of 1214 certified beds with a census of 988 patients at the time of the survey.

Findings include:

On 04/20/10 during interviews with surgical staff, the staff revealed six incidents of fire which occurred in facility operating rooms in various surgical areas. Two operating rooms in building E were noted to have incidence of fires, operation rooms #16 and #22. In one of the incidents a patient was injured due to burns. Another incident occurred in operating room
#22 in February 2010 in which a dry sponge caught fire. The third incident occurred in operating room #16 in March 2010. The March incident in operating room #16 resulted in a second degree burn of the patient. All total, three patients (#22, #54 and #55) suffered burns during a surgical procedure.

Interview on 04/27/10 with Staff L and Staff CCC revealed an investigation of the fires indicated the medical staff present in the room failed to allow adequate drying time when using an aerosol liquid skin preparation near the completion of the operative procedure. A cautery device was used prior to adequate drying of the aerosol which resulted in a flash fire. The flame was quickly extinguished, however a patient sustained a second degree burn on a small area of skin.

Review of material safety data information revealed the skin preparation used contained approximately 75 to 83 percent alcohol. The aerosol was identified as combustible and flammable.

Based on staff interview, review of product information staff interview and verification, the facility failed to ensure that requirements addressed in National Fire Protections Association (NFPA) 1999 Edition, Chapter 12, Hospital Requirements, 12-4.1.2.2 (b) Germicides, was met. The requirement states that liquid germicides used in anesthetizing locations whenever the use of cautery or electrosurgery is contemplated, shall be nonflammable. Three of 16 operating rooms in the J Building (Rooms #63, #64 and #69) were affected. The hospital had a capacity of 1214 certified beds with a census of 988 patients at the time of the survey.

Findings included:

On 04/20/10 during interviews with surgical staff, the staff revealed six incidents of fire which occurred in operating rooms. In three of the incidents three patients were injured due to burns. One incident occurred in operating room #64 in April 2009 in which the patient sustained small areas of second and third degree burns. The second incident occurred in operating room #63 also in April 2009 and involved singeing of a gauze sponge. The third incident occurred in operating room #69 in September 2009 which resulted in a small second degree burn of the patient.

Interview on 04/26/10 between 12:10 P.M. and 12:50 P.M. with Staff L and Staff CCCC, revealed that during the course of the investigation other skin preparations were discussed in relationship to the flammability of the product. Determination was that the preparations higher in flammability best met the needs for the types of surgeries. The decision was made not to change the preparations.

Further interview and review of the facility investigation on 04/27/10 with Staff L and Staff CCCC revealed that medical staff present in the rooms failed to allow adequate drying time when using liquid germicidal skin preparations in each of the incidents in which patients sustained burns. Further interview revealed the liquid germicidal products were commonly used to prepare the patients for surgery and were in the operating room, in use at the times of the fires.

On 04/28/10 the material safety data sheet for the germicidal products was obtained from the surgical area. Review of the product information for the two germicides revealed one product contained 74 percent isopropyl alcohol and the other contained 70 percent isopropyl alcohol. Both products were identified as flammable liquids on the information.

Based on observations and staff interviews, the facility failed to meet the NFPA 101 requirements at 39.2.1 and 7.1 for delayed egress locks for 2 exit discharges. This could affect all staff, patients, and visitors in this facility. The hospital's census was 988 patients.

Findings include:

A tour was conducted on 04/27/10 between 1:25 PM and 2:43 PM with Staff IIII, EEE, and DDD. Two exit discharges were observed with delayed egress door and a sign that stated audible alarm within 2 seconds, push for 30 seconds. These doors were located on the first floor at Stair R3 and the exit located in the Northwest corner of the building at 89th street and Euclid Avenue. These doors were tested and did not open until 30 seconds after constant pushing pressure. These staff (Staff III, EEE and DDD) verified the doors at the time of tour. There was no documented evidence of approval by the authority having jurisdiction.

Based on observations and staff interviews, the facility failed to meet the NFPA 101 requirements at 39.2.2.2.4 and 7.2.1.6.1. for delayed egress locks for two exit discharges, and 39.2.1.1 and 7.10.2 for exit directional signage, and failed to ensure four exit discharges were equipped with lighting fixtures that would prevent the discharge areas from being in darkness in the event that the lighting fixture (bulb) would fail, in accordance with the code at 7.8. This could affect all patients, staff, and visitors in this building. The hospital's census was 988 patients.

Findings include:

A tour was conducted in this building on 04/28/10 between 9:42 AM and 11:30 AM with Staff JJJJ, Staff EEE, Staff IIII, and Staff HHH. The following observations were made during this tour:

Exit discharge doors located at Stairwell U2, Stairwell U3, and Stairwell U5 were observed with delayed egress doors and signs that stated audible alarm within 2 seconds, push for 30 seconds. These doors were tested and did not open until 30 seconds after constant pushing pressure. The staff present verified the observation of the doors at the time of tour. There was no documented evidence of approval by the authority having jurisdiction.

The following exit discharge doors located as follows were observed with only a single bulb fixture:
Two exits in the physical therapy room, and one exit outside the Southeast ambulance entrance. An exit discharge located in the hallway by the stairs dividing the MS education area from the police station lacked any discharge lighting at the exit discharge.

The hallway outside the MRI room on the first floor lacked a directional arrow leading to the exit access door. The exit access door was not visible in the hallway until turning the corner. There were several doors located in this hallway which could be confusing to anyone attempting to exit in the event of smoke or fire.

These concerns were verified with staff accompanying the surveyor on tour.

Based on observations, review of sprinkler inspection reports, and staff interview, the facility failed to meet the requirements of NFPA 101, 39.1.5.2 and NFPA 13 for sprinkler systems by ensuring electronic or manual supervision of the sprinkler system. This could affect all patients, staff, and visitors in the facility. The hospital's census at the time of the survey was 988 patients.

Findings include:

A tour was conducted in the facility on 04/28/10 between 3:05 PM and 3:30 PM with Staff JJJJ, Staff ZZZZ, Staff CCC, and Staff AAA. The facility was observed with a complete automatic sprinkler system in place. The red post indicator valve (PIV) in the front entrance of the facility lacked mechanical means of securing the valve to protect the water supply to the sprinkler system. There was no electrical tamper control switch observed on the PIV. An interview with Staff CCC at that time verified the sprinkler system is not electronically supervised in accordance with the code, stating that it should be supervised.

An interview on 04/29/10 at 2:00 PM verified this sprinkler system is not supervised in accordance with the code. A written inspection report dated 04/29/10, and received by the surveyor at 10:30 AM on 04/30/10 verified this lack of supervision.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that one open use area on the eighth floor of the J Building was protected in accordance with 18.3.6.1. This could affect all individuals utilizing the services of this smoke compartment. The hospital's census was 988 patients.

Findings include:

Tour was conducted in the J Building from 9:00 AM until 4:30 PM on 4/22/10 with staff members GGGG, WWWW, EEEE, and FFFF. During tour of the eighth floor a waiting area was observed at the end of the corridor. This area was open to the corridor, was fully sprinklered, but lacked smoke detection. This finding was confirmed by staff EEEE during the tour.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that two open use areas were protected in accordance with NFPA 19.3.6.1. This could affect all individuals utilizing the services of the affected smoke compartments. The hospital's census was 988 patients.

Findings include:

Tour was conducted in Building M from 9:00 AM until 12:00 PM on 4/21/10 with staff members EEEE, WW, FFFF, and A6. During tour the third floor play area was observed to have sliding wooden doors to the corridor that could not be latched when closed. The room was fully sprinklered but lacked smoke detection. This finding was confirmed with staff EEEE during the tour.

Tour was conducted in Building G from 1:00 PM until 5:00 PM on 4/20/10 with staff members EEEE, HHHH, FFFF, WW, and GGGG. During tour the family lounge G5-123 was observed to have glass doors to the corridor that could not be latched when closed. The room was fully sprinklered but lacked smoke detection. This finding was confirmed with staff EEEE during the tour.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that one hazardous area on the fifth floor of the J Building was protected by the required 3/4 hour rated door. This could affect all individuals utilizing the services in this smoke compartment. The hospital's census was 988 patients.

Findings include:

Tour was conducted of the J Building from 9:00 AM until 4:30 PM on 4/22/10 with staff members GGGG, WWWW, EEEE, and FFFF. During tour of the fifth floor it was observed that soiled utility room J54-321 had a door that latched securely into the door frame and was on a self-closer; however, the door lacked the required 3/4 hour fire resistance rating. This finding was confirmed by staff EEEE during the tour.

Based on facility observation and staff interview and verification, the facility failed to ensure that exit access was arranged so that exits were readily available at all times. One exit in Building S was affected. The hospital had a capacity of 1214 certified beds with a census of 988 patients at the time of the survey.

Findings include:

On 04/26/10 between the hours of 7:30 AM and 5:00 P.M. a tour of the S Building was completed with Staff EEEE and Staff FFFF. On the first floor at the outpatient laboratory area, an exit corridor was followed to determine the point of exit discharge. The exit door was numbered S-15 exit and was adjacent to S1-03, a pediatric area. An attempt to open the door failed when pressure was applied. A key swipe was noted near the exit door. Staff EEEE verified that the exit door was not to require special unlocking maneuvers and was designated as an exit for the general public to utilize.

Based on observations and staff interviews, the facility failed to ensure one set of delayed egress exit access doors on the lower level were readily accessible in accordance with section 7.1 and 19.2.1. This could affect all staff and visitors in this area. The hospital's census was 988 patients.

Findings include:

A tour was conducted on 04/27/10 between 9:53 AM and 11:50 AM with Staff IIII , Staff EEE and Staff DDD. During this tour, an exit access located by the dock was observed with two leaves of doors that were on a magnetic locking device. The sign on the doors stated PUSH UNTIL ALARMS SOUNDS, DOOR CAN BE OPENED IN 15 SECONDS. These doors were tested three times by the surveyor, and Staff DDD and Staff EEE. The alarm did not sound, the doors failed to open with pushing pressure, and failed to emit an audible alarm in accordance with the code section 7.1 (NFPA 101, 2000 Code). This was verified with both staff (Staff DDD and EEE) at the time of the testing.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that one of three sliding horizontal fire doors in the Q Building was capable of closing in the event of fire. The hospital's census was 988 patients.

Findings include:

Tour of the Q Building was conducted on 4/21/10 from 1:00 PM until 4:30 PM with staff JJJJ, EEEE, and LLLL. At approximately 4:15 PM the three McKeon sliding horizontal fire doors separating the Q Building from the J Building were observed. The door located adjacent to the chapel was observed with a large, heavy riding-type floor scrubber parked unattended in front of the fire door. Staff present on tour needed to mount the scrubber, determine how to start the machine, and drive it out of the way of the McKeon door. It was confirmed with staff present during the tour that this heavy machine would have prevented the closing of the fire door if a fire had occurred.

Based on facility observation and staff interview and verification, the facility failed to ensure that a horizontal door used as a fire door closed properly. One door ( T1-51) was affected. The hospital had a capacity of 1214 certified beds with a census of 988 patients at the time of the survey

Findings include:

On 04/26/10 between the hours of 7:30 AM and 5:00 P.M. a tour of the S Building was completed with Staff EEEE and Staff FFFF. At 4:08 p.m., on the first floor, a fire shutter was observed to be in place between the S building and the T building. Staff EEEE was asked to provide demonstration the door could function without problem. An attempt to activate the fire shutter by Staff EEEE was initiated but the door failed to close. Staff EEEE verified the fire shutter did not operate correctly and that repairs would be made immediately. Staff EEEE stated the facility's fire watch plan would be immediately implemented while repair took place.

On 04/27/10 at 10:15 A.M., Staff A8 verified the fire shutter was repaired. Staff A8 demonstrated the door operated correctly and closed securely. Review of preventative maintenance records revealed the fire shutter had been tested annually and on 09/14/09.

Based on staff interviews, and observations, the facility failed to ensure 3 of 4 exit discharges were equipped with lighting fixtures that would prevent the discharge areas from being in darkness in the event that the lighting fixture (bulb) would fail, in accordance with the code at 7.8. This could affect all patients, staff, and visitors in this facility. The hospital's census was 988 patients.

Findings include:

A tour was conducted on 04/27/10 between 9:53 AM and 11:50 AM with Staff IIII, Staff EEE and Staff DDD. The following exits were observed with a single light fixture that contained one bulb: outside Stair E1 at 90th Street and Carnegie Street, outside Stair E2 on Carnegie Street by the skywalk, and outside Stair E4 on 90th Street on the west side of the building. There were no additional light fixtures observed in these areas. These light fixture bulbs were verified by the staff accompanying the surveyor on tour.

Based on observations and staff interviews, the facility failed to insure the fire alarm system is installed in accordance with NFPA 70 National Electrical Code and NFPA 72, 9.6.1.4. This involved one smoke detector in the building on the first floor and could affect all staff and visitors in that building. The hospital's census was 988 patients.

Findings include:

A tour was conducted in this building on 04/28/10 between 9:42 AM and 11:30 AM with Staff JJJJ, Staff EEE, and Staff HHH. The main fire panel in the first floor lobby was observed with a system trouble light. When questioned as to why the panel had a system trouble light, Staff IIII was notified by facility staff, who then notified Staff III to explain this to the surveyor. Staff III stated a new smoke detector had been installed approximately 1 to 2 months ago in the MRI unit; however, had not been fully interconnected into the fire alarm system, resulting in a system trouble light on the main fire panel. Staff IIII stated the outside contractor would be contacted to finish the work. On 04/30/10 at 11:30 AM, Staff IIII stated the smoke detector is now connected into the fire alarm system.

Based on observations and staff interviews, the facility failed to maintain sprinkler heads and escheon rings on the first floor of the E building. This involved multiple areas of this floor and could affect all the patients in the emergency room and intensive care overflow area (12 beds), along with visitors, and staff. The code at NFPA 25, 9.7.5. The hospital's census was 988 patients.


Findings include:


A tour was conducted on 04/27/10 between 9:53 AM and 11:50 AM with Staff IIII , Staff EEE and Staff DDD. During this tour, on the first floor, dirty, heavily coated sprinkler heads or missing escheon rings were observed in the following areas:

In the ICU spill over unit rooms the sprinkler heads were observed dirty: #12, #10, #9, #8, #5, #4, #2, #1 and by the ambulance exit.
Escheon rings were missing in the ICU spill over unit in the following areas: by room E1-347, two by the elevator and hall dock area, by the coumadin clinic E1-225, in the Coumadin work room and at the entrance at E-13.

In the emergency department (ED), the following sprinkler heads were dusty/dirty:
Three sprinkler heads at the entrance into the unit, three in security office, outside security, behind the ED registration desk, by E1-147, two inside the ambulance entrance, by E1-126, outside E1-101, Room #16, and #18 additional sprinkler heads in the nurses' station and surrounding hallway.

In the E-17 unit dirty sprinkler heads were observed at the nurses' stations, in the conference room, and in the hall by room #2. An escheon ring was missing in EB-20.

In the observation area dirty sprinkler heads were observed outside beds #13, #10, #9 and at the nurses' station, in room #2.

These sprinkler heads were verified with Staff IIII on tour who confirmed the heads were in need of cleaning or needing replacement of escheon rings.

Based on observations made during tour and staff interview, it was determined that the facility failed to ensure that medical gases were stored according to NFPA 99 in the surgery exit hallway on the fourth floor of the J Building. This could affect all individuals in this smoke compartment. The hospital's census was 988 patients.

Findings include:

Tour was conducted in the J Building from 9:00 AM until 4:30 PM on 4/22/10 with staff members GGGG, WWWW, EEEE, and FFFF. During tour of the fourth floor, it was noted that medical gases exceeding 300 cubic feet were stored in the surgery exit corridor. The medical gases observed were: one M tank of compressed air, one H tank of compressed air; four M tanks of argon; one H tank of argon; four D tanks of helium; and four M tanks of nitrous oxide. It was confirmed by staff EEEE during the tour that these medical gases should not be stored in the open exit corridor.

Based on observations and staff interviews, the facility failed to ensure two oxygen cylinders were secured and protected in accordance with NFPA 99, 4-3.1.1.2. This affected patients in the Intensive Care spill over unit and in the emergency room, as well as all visitors, and staff on the first floor of the E building. The hospital census was 988 patients.

Findings include:

A tour was conducted on 04/27/10 between 9:53 AM and 11:50 AM with Staff DDD. The respiratory therapy room of that unit was observed with 6 E-size oxygen tanks in a rack. Near the rack, two E-tanks of oxygen were observed lying unattended on the floor. One of the two tanks contained approximately a half tank of oxygen. This was verified with Staff DDD at that time.

Based on facility observation, review of facility information and staff interview and verification, the facility failed to ensure that relative humidity was maintained equal to or greater than 35% in anesthetizing locations. The facility had 89 operating rooms located on the main campus of the facility. Two of six buildings that housed operating rooms (Buildings H and G) were affected. Building H contained 13 operating rooms. Building G contained 11 operating rooms. The hospital had a capacity of 1214 certified beds with a census of 988 patients at the time of the survey.

Findings include:

1. On 04/20/10 between 1:30 PM and 4:00 PM during tour, the monitoring location for the hospital's operating rooms humidity levels was observed with staff IIII. Staff XX and Staff A5 were present in the monitoring location. Staff A5 was asked to provide documented humidity levels for the facility's operating rooms. Staff A5 indicated that all the operating rooms humidity levels were electronically monitored and to print the information would require too many pages. Staff A5 provided a sample of one operating room located in the H building. The humidity level for the room was noted to have a high and low reading. The low was 12 percent with the high reading being 20 percent.

The staff (Staff XX and A5) indicated the electronic monitoring involved three systems. Staff XX and Staff A5 indicated that it may not be possible to obtain readings for some operating rooms. The staff was asked to provide 3 days of information, for the H building with the random dates chosen as 02/03, 02/04, and 02/05/10.

On 04/21/10, the information was provided. Review of the humidity levels for the 13 operating rooms in Building H revealed 13 of 13 operating rooms did not reach 35 percent on the dates chosen for review. All humidity levels were noted to be under 28 percent.

Staff XX and Staff A5 could not address what the desired level of humidity was for the facility's operating rooms. Review of the facility policy for environmental control revealed the surgical services locations were to have humidity levels maintained between 30 and 60 percent for ideal conditions related to health and safety.

On 04/23/10 at 10:30 A.M. interview of Staff XX revealed that operating rooms were not notified if humidity levels were too low. Staff XX stated that only when humidity levels become too high were the operating room staff notified.

On 04/28/10 at 10:25 A.M. Staff A5 obtained humidity levels for 13 operating rooms in Building H. Thirteen of 13 operating rooms had humidity levels below 35 percent. The ranges of the humidity levels for the 13 operating rooms were 19.69 percent to 30.03 percent. Humidity levels were also reviewed for 11 operating rooms located in Building G. Eleven of 11 operating rooms in Building G did not have humidity levels of 35 percent of greater. The ranges of humidity levels for the 11 operating rooms were 22.12 percent to 25.85 percent.

Based on facility observation, review of facility policy and staff interview and verification, the facility failed to ensure that relative humidity was maintained equal to or greater than 35% in anesthetizing locations. The facility had 89 operating rooms located on the main campus of the facility. Building E contained 25 operating rooms. Two of 25 rooms (Rooms #16 and #22) was affected. The hospital had a capacity of 1214 certified beds with a census of 988 patients at the time of the survey.

Findings include:

1. On 04/23/10 at 10:35 AM, Staff XX was asked to provided relative humidity levels for two operating rooms in Building E, operating rooms #16 and #22. Staff XX was in the monitor location where the facility's operating room's humidity readings were electronically monitored. According to Staff XX, while all the operating room's humidity levels were electronically monitored the systems utilized by the facility maintained data for limited intervals.

The humidity level for room #16 at that time was noted to be 18.8 percent. No reading could be obtained for operating room #22.

On 04/28/10 at 10:15 A.M. Staff A5, was asked to provide the most current humidity levels for the same two operating rooms. Operating room #16 had a humidity level of 19.4 percent and operating room #22 had a humidity level of 26.4 percent. Staff A5 verified the set percent for the room was 45 percent.

Review of the facility policy for environmental control revealed the surgical services locations were to have humidity levels maintained between 30 and 60 percent for ideal conditions related to health and safety.



03245

Doors shall be operable with not more than one releasing operation. 39.2.2.2.1, 7.2.1.5.4.

This requirement is NOT MET as evidenced by:

Based on observation and interview, it was determined that the facility failed to ensure that two of two sleeping rooms could be opened with not more than one releasing operation. The hospital's census was 988 patients.

Findings include:

Tour was conducted on 4/26/10 from 12:45 PM until 1:15 PM with staff JJJJ, staff MMMM, and individual YYYY. It was observed that the two patient sleeping room doors had handles with a device for latching the doors into the door frame. The doors also had deadbolts located approximately eight inches above the handles. If the deadbolts were secured, this would require any individual in the rooms to use two hand motions to release both locks before exiting the rooms. This finding was confirmed by staff JJJJ and individual YYYY during the tour.

Based on staff interview, review of product information and staff interview and verification, the facility failed to ensure that requirements addressed in National Fire Protections Association (NFPA) 1999 Edition, Chapter 12, Hospital Requirements, 12-4.1.2.2 (b) Germicides, was met. The requirement states that liquid germicides used in anesthetizing locations whenever the use of cautery or electrosurgery is contemplated, shall be nonflammable. Two of 25 operating rooms in the E Building (Rooms #16 and #22) were affected. The hospital had a capacity of 1214 certified beds with a census of 988 patients at the time of the survey.

Findings include:

On 04/20/10 during interviews with surgical staff, the staff revealed six incidents of fire which occurred in facility operating rooms in various surgical areas. Two operating rooms in building E were noted to have incidence of fires, operation rooms #16 and #22. In one of the incidents a patient was injured due to burns. Another incident occurred in operating room
#22 in February 2010 in which a dry sponge caught fire. The third incident occurred in operating room #16 in March 2010. The March incident in operating room #16 resulted in a second degree burn of the patient. All total, three patients (#22, #54 and #55) suffered burns during a surgical procedure.

Interview on 04/27/10 with Staff L and Staff CCC revealed an investigation of the fires indicated the medical staff present in the room failed to allow adequate drying time when using an aerosol liquid skin preparation near the completion of the operative procedure. A cautery device was used prior to adequate drying of the aerosol which resulted in a flash fire. The flame was quickly extinguished, however a patient sustained a second degree burn on a small area of skin.

Review of material safety data information revealed the skin preparation used contained approximately 75 to 83 percent alcohol. The aerosol was identified as combustible and flammable.

Based on staff interview, review of product information staff interview and verification, the facility failed to ensure that requirements addressed in National Fire Protections Association (NFPA) 1999 Edition, Chapter 12, Hospital Requirements, 12-4.1.2.2 (b) Germicides, was met. The requirement states that liquid germicides used in anesthetizing locations whenever the use of cautery or electrosurgery is contemplated, shall be nonflammable. Three of 16 operating rooms in the J Building (Rooms #63, #64 and #69) were affected. The hospital had a capacity of 1214 certified beds with a census of 988 patients at the time of the survey.

Findings included:

On 04/20/10 during interviews with surgical staff, the staff revealed six incidents of fire which occurred in operating rooms. In three of the incidents three patients were injured due to burns. One incident occurred in operating room #64 in April 2009 in which the patient sustained small areas of second and third degree burns. The second incident occurred in operating room #63 also in April 2009 and involved singeing of a gauze sponge. The third incident occurred in operating room #69 in September 2009 which resulted in a small second degree burn of the patient.

Interview on 04/26/10 between 12:10 P.M. and 12:50 P.M. with Staff L and Staff CCCC, revealed that during the course of the investigation other skin preparations were discussed in relationship to the flammability of the product. Determination was that the preparations higher in flammability best met the needs for the types of surgeries. The decision was made not to change the preparations.

Further interview and review of the facility investigation on 04/27/10 with Staff L and Staff CCCC revealed that medical staff present in the rooms failed to allow adequate drying time when using liquid germicidal skin preparations in each of the incidents in which patients sustained burns. Further interview revealed the liquid germicidal products were commonly used to prepare the patients for surgery and were in the operating room, in use at the times of the fires.

On 04/28/10 the material safety data sheet for the germicidal products was obtained from the surgical area. Review of the product information for the two germicides revealed one product contained 74 percent isopropyl alcohol and the other contained 70 percent isopropyl alcohol. Both products were identified as flammable liquids on the information.

Based on observations and staff interviews, the facility failed to meet the NFPA 101 requirements at 39.2.1 and 7.1 for delayed egress locks for 2 exit discharges. This could affect all staff, patients, and visitors in this facility. The hospital's census was 988 patients.

Findings include:

A tour was conducted on 04/27/10 between 1:25 PM and 2:43 PM with Staff IIII, EEE, and DDD. Two exit discharges were observed with delayed egress door and a sign that stated audible alarm within 2 seconds, push for 30 seconds. These doors were located on the first floor at Stair R3 and the exit located in the Northwest corner of the building at 89th street and Euclid Avenue. These doors were tested and did not open until 30 seconds after constant pushing pressure. These staff (Staff III, EEE and DDD) verified the doors at the time of tour. There was no documented evidence of approval by the authority having jurisdiction.

Based on observations and staff interviews, the facility failed to meet the NFPA 101 requirements at 39.2.2.2.4 and 7.2.1.6.1. for delayed egress locks for two exit discharges, and 39.2.1.1 and 7.10.2 for exit directional signage, and failed to ensure four exit discharges were equipped with lighting fixtures that would prevent the discharge areas from being in darkness in the event that the lighting fixture (bulb) would fail, in accordance with the code at 7.8. This could affect all patients, staff, and visitors in this building. The hospital's census was 988 patients.

Findings include:

A tour was conducted in this building on 04/28/10 between 9:42 AM and 11:30 AM with Staff JJJJ, Staff EEE, Staff IIII, and Staff HHH. The following observations were made during this tour:

Exit discharge doors located at Stairwell U2, Stairwell U3, and Stairwell U5 were observed with delayed egress doors and signs that stated audible alarm within 2 seconds, push for 30 seconds. These doors were tested and did not open until 30 seconds after constant pushing pressure. The staff present verified the observation of the doors at the time of tour. There was no documented evidence of approval by the authority having jurisdiction.

The following exit discharge doors located as follows were observed with only a single bulb fixture:
Two exits in the physical therapy room, and one exit outside the Southeast ambulance entrance. An exit discharge located in the hallway by the stairs dividing the MS education area from the police station lacked any discharge lighting at the exit discharge.

The hallway outside the MRI room on the first floor lacked a directional arrow leading to the exit access door. The exit access door was not visible in the hallway until turning the corner. There were several doors located in this hallway which could be confusing to anyone attempting to exit in the event of smoke or fire.

These concerns were verified with staff accompanying the surveyor on tour.

Based on observations, review of sprinkler inspection reports, and staff interview, the facility failed to meet the requirements of NFPA 101, 39.1.5.2 and NFPA 13 for sprinkler systems by ensuring electronic or manual supervision of the sprinkler system. This could affect all patients, staff, and visitors in the facility. The hospital's census at the time of the survey was 988 patients.

Findings include:

A tour was conducted in the facility on 04/28/10 between 3:05 PM and 3:30 PM with Staff JJJJ, Staff ZZZZ, Staff CCC, and Staff AAA. The facility was observed with a complete automatic sprinkler system in place. The red post indicator valve (PIV) in the front entrance of the facility lacked mechanical means of securing the valve to protect the water supply to the sprinkler system. There was no electrical tamper control switch observed on the PIV. An interview with Staff CCC at that time verified the sprinkler system is not electronically supervised in accordance with the code, stating that it should be supervised.

An interview on 04/29/10 at 2:00 PM verified this sprinkler system is not supervised in accordance with the code. A written inspection report dated 04/29/10, and received by the surveyor at 10:30 AM on 04/30/10 verified this lack of supervision.