HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure that the access to exits are marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. 7.10.1.4

Findings included but were not limited to:

1. No exit signs were provided in the recovery suite to direct patients and staff in the event of fire or smoke.
2. No exit signs were provided in the Cath Lab suite to direct patients and staff to the outside of the suite in event of fire or smoke.
3. There were no illuminated exit signs to direct patients and staff to outside the unit in the event of smoke or fire. Examples included but were not limited to the waiting area and the outpatient Gym 6N16
4. The exit door next to room 7W51 of the pulmonary unit on the 7th floor did not have illuminated exit sign.
5. The exit door next to room 7S37 of the pulmonary unit on the 7th floor did not have illuminated exit sign.
6. There was no illuminated exit sign provided on the work service corridor of the nuclear medicine and the ultrasound unit of the radiology suite.
7. No illuminated exit sign was provided at the exit door of the CT scan suite.
8. No exit signs were provided in the hematology lab.
9. No exit signs were provided at the corridor of the chemistry lab and by the exit door next to 4S12B.

Based on observation, the facility failed to maintain the continuity of the smoke barriers by not protecting the space between the penetrating item and the smoke barrier.

Findings include:

During the tour of the emergency department on 08/27/2012, it was noted that there were unsealed penetrations around the conduits passing through the smoke barrier wall above the ER door #2 and the two smoke barrier walls built around the urgent care area.

During the tour of the Child CPEP unit on 08/27/12, two unsealed penetrations were noted on the wall of the telecommunication closet around the telecommunication cables that penetrated the left side of the one hour fire resistant barriers.

On 08/31/12, during the tour of the pharmacy department on 14 S, the surveyor noted an unsealed penetration caused by penetrating cables on the a smoke barrier wall between the elevator lobby and service elevator lobby.





21204


During a tour of the rehab unit on the 6th floor on the morning of 8/29/2012, it was noted that:
1. The smoke barrier above smoke door near 6N5 was found to have penetrations around electric wirings, cable wirings and conduits wirings that were not sealed by the proper fire stops.
2. The smoke barrier above the smoke door that is next to 6N14B was found to have penetrations around conduits and cable wirings that were not sealed by the proper fire stops.
During a tour of the radiology suite on the morning of 8/30/2012, it was noted that the fire barrier above the fire door next to room 3E15 had penetration that was not sealed properly by the fire stops.
During a tour of the laboratory department on the morning of 8/31/2012, there were two penetrations at the two-hour fire rated ceiling of the electric closet 4S7.

Based on observation and staff interview, the facility failed to ensure that the access to exits are marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. 7.10.1.4

Findings included but were not limited to:

1. No exit signs were provided in the recovery suite to direct patients and staff in the event of fire or smoke.
2. No exit signs were provided in the Cath Lab suite to direct patients and staff to the outside of the suite in event of fire or smoke.
3. There were no illuminated exit signs to direct patients and staff to outside the unit in the event of smoke or fire. Examples included but were not limited to the waiting area and the outpatient Gym 6N16
4. The exit door next to room 7W51 of the pulmonary unit on the 7th floor did not have illuminated exit sign.
5. The exit door next to room 7S37 of the pulmonary unit on the 7th floor did not have illuminated exit sign.
6. There was no illuminated exit sign provided on the work service corridor of the nuclear medicine and the ultrasound unit of the radiology suite.
7. No illuminated exit sign was provided at the exit door of the CT scan suite.
8. No exit signs were provided in the hematology lab.
9. No exit signs were provided at the corridor of the chemistry lab and by the exit door next to 4S12B.

Based on observation, the facility failed to maintain the continuity of the smoke barriers by not protecting the space between the penetrating item and the smoke barrier.

Findings include:

During the tour of the emergency department on 08/27/2012, it was noted that there were unsealed penetrations around the conduits passing through the smoke barrier wall above the ER door #2 and the two smoke barrier walls built around the urgent care area.

During the tour of the Child CPEP unit on 08/27/12, two unsealed penetrations were noted on the wall of the telecommunication closet around the telecommunication cables that penetrated the left side of the one hour fire resistant barriers.

On 08/31/12, during the tour of the pharmacy department on 14 S, the surveyor noted an unsealed penetration caused by penetrating cables on the a smoke barrier wall between the elevator lobby and service elevator lobby.





21204


During a tour of the rehab unit on the 6th floor on the morning of 8/29/2012, it was noted that:
1. The smoke barrier above smoke door near 6N5 was found to have penetrations around electric wirings, cable wirings and conduits wirings that were not sealed by the proper fire stops.
2. The smoke barrier above the smoke door that is next to 6N14B was found to have penetrations around conduits and cable wirings that were not sealed by the proper fire stops.
During a tour of the radiology suite on the morning of 8/30/2012, it was noted that the fire barrier above the fire door next to room 3E15 had penetration that was not sealed properly by the fire stops.
During a tour of the laboratory department on the morning of 8/31/2012, there were two penetrations at the two-hour fire rated ceiling of the electric closet 4S7.