HospitalInspections.org

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1) Based on observation and interview, the facility failed to ensure that all corridor doors were provided with approved positive latching hardware. NFPA 101-2000 Life Safety Code Section 19.3.6.3.2 requires that corridor doors in Existing Health Care Occupancies be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction (e.g., doors shall be provided with positive latching hardware). Specific reference is made to the lack of positive latching hardware (e.g., automatic flush bolts).

Findings:

From 08/11/14 through 08/15/14, between 9:00AM and 3:00PM, the inactive leaf to two (2) sets of double doors on end rooms on the East and West Sides of the Dynamic Care Building (DCB) was found to be provided with concealed manually operated flush bolts that would take more than one (1) operation to secure in the event of a fire. This was noted on the 18th, 14th, 12th, 11th, 10th, 9th, 7th, 6th and 5th Floors and the Blood Donor Room on the Ground Floor.

In an interview on 08/12/14 at approximately 11:50AM, Staff #24 stated that they would have the manual flush bolts replaced with automatic flush bolts.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.3.2


2) Based on observation and interview, the facility failed to ensure that all corridor doors were provided with approved positive latching hardware. NFPA 101-2000 Life Safety Code Section 18.3.6.3.3 requires that there is no impediment to the closing of corridor doors in New Health Care Occupancies. If facility building plans were approved, or a building permit issued, or construction started after March 13, 2003, the building or addition must be surveyed under the 2000 New Health Care Occupancy Chapter. Specific reference is made to the sliding doors for the Treatment Rooms in the Emergency Department (ED) hanging up on the tracks, preventing them from positively latching.

Findings:

On 08/14/14 between 11:30AM and 12:15PM, the sliding doors for Treatment Rooms #7, #8 and #10 in the ED hung up on the tracks, preventing the corridor doors from positively latching.

In an interview on 08/14/14 at approximately 11:49AM, Staff #24 stated that they would have all of the Treatment Room doors checked and adjusted as necessary.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 18.3.6.3.3


3) Based on observation and interview, the facility failed to ensure that the undercut for corridor doors does not exceed one (1) inch. NFPA 101-2000 Life Safety Code Section 19.3.6.3.1 requires that the clearance between the bottom of the door and the floor covering does not exceed one (1) inch for corridor doors in Existing Health Care Occupancies. This was noted on the 14th Floor.

Findings:

On 08/12/14 between 9:35AM and 9:46AM, the clearance between the bottom of the door and the floor in Rooms #1454, #1455 and #1431 ranged from approximately one and one-quarter (1¼) inches to one and one-half (1½) inches.

In an interview on 08/12/14 at approximately 9:36AM, Staff #24 stated that they would have sweeps installed on the doors.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.3.1
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Based on observation and interview, the facility failed to ensure that plain glass vision panels that were installed as part of corridor doors on the 4th and 12th Floors shall be fixed window assemblies in approved frames. The rooms were located within partially sprinklered smoke compartments and there were no fire-rated labels on the glass and/or door assembly, contrary to the requirement that vision panels in corridor doors shall be fixed window assemblies in approved frames.

Findings:

On 08/12/14 between 9:00AM and 10:30PM, approximately thirty-four (34) inch by thirty (30) inch plain glass vision panels were installed as part of the corridor doors on the 12th and 14th Floors. Examples are Rooms #1244, #1243, #1441 and #1444.

The rooms were located in smoke compartments that were partially sprinklered (i.e. only the hazardous areas were provided with sprinkler coverage) and there were no fire-rated labels on the glass and/or door assembly.

In an interview on 08/12/14 at approximately 9:21AM, Staff #24 stated that they would make Administration aware of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.3.8
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2000 NFPA 101: 8.2.5.4*
The fire resistance rating for the enclosure of floor openings shall be not less than as follows (see 7.1.3.2.1 for enclosure of exits):
(1) Enclosures connecting four (4) stories or more in new construction - two (2) hour fire barriers.
(2) Other enclosures in new construction - one (1) hour fire barriers.
(3) Existing enclosures in existing buildings - one-half (½) hour fire barriers.
(4) As specified in Chapter 26 for lodging and rooming houses, in Chapter 28 for new hotels, and in Chapter 30 for new apartment buildings.


Based on observation and interview, the facility failed to ensure that the mechanical shaft in the vicinity of the Elevator Lobby on the 19th Floor was provided with a two (2) hour fire barrier.

Findings:

On 08/11/14 at approximately 10:45AM, the mechanical shaft in the vicinity of the Elevator Lobby on the 19th Floor was noted not provided with a two (2) hour fire barrier in that the door was not positively latching when tested and two (2) unsealed conduit penetrations were noted above the door to the shaft.

In an interview on 08/11/14 at this time, Staff #24 stated that the door would be fixed and the conduit penetrations would be sealed immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 8.2.5.4
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2000 NFPA 101: 19.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than one-half (½) hour.


Based on observation and interview, the facility failed to ensure that smoke barrier walls were constructed to have at least a one-half (½) hour fire resistance rating in that unsealed penetrations around wires and conduits, cut holes, improperly sealed, and unfinished wall assemblies were noted in smoke barrier walls on the 6th, 3rd, 2nd and 1st Floors.

Findings:

On 08/13/14 and 08/14/14, between 9:00AM and 3:00PM, unsealed penetrations around wires and conduits, cut holes, improperly sealed, and unfinished wall assemblies were noted in smoke barrier walls on the 6th, 3rd, 2nd and 1st Floors. Examples include but are not limited to the following:

a) 6th FLOOR:
i) Cable penetration within the Storage Room in the vicinity of the public Elevator Lobby.

ii) Multiple penetrations around pipe and conduit and an approximately three (3) inch diameter penetration around a sprinkler pipe in Clean Utility Room #621.

iii) Penetrations around conduit and between wires within conduit above the smoke barrier doors in the vicinity of Stair 2 in the North Corridor.

iv. Unsealed top-of-wall assembly above the smoke barrier doors in the South Corridor.

b) 3rd FLOOR:
i) Multiple penetrations within and around conduit above the smoke barrier doors in the vicinity of Stair #6.

ii) Multiple penetrations around wires and conduit above the smoke barrier doors in the vicinity of Room #3143.

iii) The Life Safety drawings provided by the facility indicate that the smoke barrier runs across two (2) open alcoves in the vicinity of Room #3309. Smoke barriers are continuous walls from outside to outside.

c) 2nd FLOOR:
i) Penetrations around a bundle of wires and within conduit above the smoke barrier doors in the Center Corridor to the ICU (Intensive Care Unit).

ii) Penetrations around conduit and wires in the electrical closet in the vicinity of Breast Imaging.

d) 1st FLOOR:
i. Approximately three (3) inch by three (3) inch and six (6) inch by six (6) inch square cut outs and a four (4) inch diameter penetration around a BX conduit above the smoke barrier doors to the ED (Emergency Department).

ii) An insulated pipe was sealed with joint compound and not an approved fire-stopping material in the Ultrasound Bathroom.


In an interview on 08/13/14 at approximately 9:39AM, Staff #24 stated that the penetrations would be sealed immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7.3, 8.3, 8.2.3
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2000 NFPA 101: 19.3.7.5
Openings in smoke barriers shall be protected by fire-rated glazing; by wired glass panels and steel frames; by substantial doors, such as one and three-quarter (1¾) inch (4.4cm) thick, solid-bonded wood core doors; or by construction that resists fire for not less than twenty (20) minutes. Nonrated factory - or field-applied protective plates extending not more than forty-eight (48) inches (122cm) above the bottom of the door shall be permitted.

Exception: Doors shall be permitted to have fixed fire window assemblies in accordance with 8.2.3.2.2.


1) Based on observation and interview, the facility failed to ensure that smoke barrier doors were provided with self-closing devices. This was noted on the 14th, 12th, 3rd and 2nd Floors.

Findings:

From 08/12/14 through 08/14/14, between 9:00AM and 3:00PM, doors to rooms that were part of the smoke barrier, as indicated by the facility's Life Safety Drawings, were not provided with self-closing devices. Examples are:

a) 14th Floor - Rooms #1428 and #1458.

b) 12th Floor - Rooms #1256 and #1230.

c) 3rd Floor - Storage Closet Room #3302.

d) 2nd Floor - Lounge Room #2141 and Conference Room #2348.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7.6

In an interview on 08/12/14 at approximately 9:30AM, Staff #24 stated that all of the smoke barrier walls would be re-evaluated in relation to the Life Safety Drawings.


2) Based on observation and interview, the facility failed to ensure that smoke barrier doors were constructed to resist fire for not less than twenty (20) minutes. This was noted on the 14th and 2nd Floors.

Findings:

From 08/12/14 through 8/14/14, between 9:00AM and 3:00PM, the following smoke barrier doors were not provided with labels or documentation to indicate construction that resists fire for not less than twenty (20) minutes. Examples are:

a) The door to Room #1417 on the South Corridor lacked a fire-rated label on the door or frame.

b) The door to the Respiratory Office on the 2nd Floor was noted with an approximately eighteen (18) inch by thirty-two (32) inch (five hundred seventy-six {576} square inches) plain glass vision panel. There was no fire-rated label on the glass or frame assembly.


In an interview on 08/14/14 at approximately 10:13AM, Staff #24 stated that the issues with the smoke barrier doors would be addressed.

2000 NFPA 101: 19.3.7.5
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1) Based on observation and interview, the facility failed to ensure that all door openings from hazardous areas were protected by self-closing, positive latching doors. This was noted on the 18th, 9th, 6th and 3rd Floors.

Findings:

a) From 08/11/14 through 08/14/14, between 9:00AM and 3:00PM, doors, when released, hit the frame and were not positively latching. Examples are:

i) 18th Floor Soiled Utility Room #1816.

ii) 9th Floor Soiled Utility Rooms #916 and #904.


b) From 08/11/14 through 8/14/14 between 9:00AM and 3:00PM, doors lacked a self-closing device. Examples are:

i) 6th Floor Storage Room in the vicinity of the public Elevator Lobby.

ii) Room #3117, which was being used for storage and was greater than fifty (50) square feet.


In an interview on 08/13/14 at approximately 11:55AM, Staff #24 stated that the doors would be fixed and that approved self-closing or automatic closing devices would be installed on all of the above-mentioned doors.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.1


2) Based on observation and interview, the facility failed to ensure that hazardous areas lacking sprinkler coverage were provided with one (1) hour fire rated construction with three-quarter (¾) hour fire-rated doors. This was noted on the 18th and 5th Floors.

Findings:

From 08/11/14 through 08/13/14, between 9:00AM and 3:00PM, hazardous areas lacking sprinkler coverage were not provided with one (1) hour fire rated construction with three-quarter (¾) hour fire-rated doors. Examples are:

a) The Storage Room on the 18th Floor adjacent to the Recreation Room lacked both sprinkler coverage and a fire-rated label on the door.

b) Storage Room #546 lacked both sprinkler coverage and a self-closing device. Additionally, the door had a twenty (20) minute fire-rated label instead of the required three-quarter (¾) hour fire-rating.


In an interview on 08/13/14 at approximately 10:41AM, Staff #24 stated that the facility will address the issues immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.1
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Based on observation and interview, the facility failed to ensure that exit enclosures (such as stairways) were enclosed with construction having a fire resistance rating of at least two (2) hours. This was noted on the 19th, 3rd and Ground Floors.

Findings:

From 08/11/14 through 08/15/14, between 9:00AM and 3:00PM, exit enclosures and exit passageways were not enclosed with construction having a fire resistance rating of at least two (2) hours and did not provide protection against fire or smoke from other parts of the building. Examples include:

a) An unsealed penetration was noted around a duct passing into the Psychiatric Emergency Department from the exit passageway from Stair #1 on the Ground Floor.

b) A broken self-closing device was noted on the "Old EMS (Emergency Medical Services) Break Room" within the exit passageway from Stair #6 on the Ground Floor.

c) An approximately six (6) inch diameter conduit was noted incorporated as part of the Stair #3 enclosure on the 3rd Floor.

d) Two (2) wire penetrations were noted above the door to Stair #2 on the 19th Floor.

In an interview on 08/15/14 at approximately 10:25AM, Staff #24 stated that all issues would be addressed immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 7.1.3.2, 8.2.5.2, 8.2.5.4, 19.3.1.1
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Based on observation and interview, the facility failed to ensure that exit access is so arranged that exits are readily accessible at all times in that two (2) Personal Care Aides (PCAs) on the 14th Floor were unaware which key unlocks the two (2) Exit Stair Doors.

Findings:

On 08/12/14 at approximately 9:45AM, two (2) PCAs on the 14th Floor Locked Unit were interviewed in the presence of the Director of Engineering and the Nurse Manager and were unaware as to which key unlocked the two (2) Exit Stair Doors.

In an interview on 08/12/14 at this time, the Nurse Manager stated that the staff would be re-inserviced immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 7.1, 19.2.1
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2000 NFPA 101: 7.10.1.3 Exit Stair Door Tactile Signage Tactile signage shall be located at each door into an exit stair enclosure, and such signage shall read as follows:
EXIT
Signage shall comply with CABO / ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, and shall be installed adjacent to the latch side of the door sixty (60) inches (152cm) above the finished floor to the centerline of the sign.


Based on observation and interview, the facility failed to ensure that exit stair door tactile signage was provided on the latch side of the door for stairs on the 6th, 3rd and 2nd Floors.

Findings:

From 08/13/14 through 08/14/14, between 9:00AM and 3:00PM, exit stair door tactile signage was not provided on the latch side of the door for two (2) of three (3) stairs in the building. Examples are:

a) 6th Floor - North Corridor Side for Stairs #2 and #3.

b) 3rd Floor - Stairs #1 and #6 and the South Corridor Side for Stair #3.

c) 2nd Floor - Stair #9.

In an interview on 08/14/14 at approximately 9:36AM, Staff #24 stated that they would have the tactile signs installed immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 7.10.1.3
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Based on observation and interview, the facility failed to ensure that fire alarm system initiating devices (e.g., smoke detectors) were properly maintained.

Findings:

a) On 08/11/14 at approximately 10:30AM, a smoke detector in the "Tele Health Room" on the 19th Floor was noted to be capped.

b) On 08/11/14 at approximately 10:55AM, a smoke detector in the West Electrical Room on the 19th Floor was noted to be capped.

c) On 8/13/14 at approximately 10:37AM, two (2) smoke detectors above patient beds in Room #550 were noted to be covered with duct tape.

d) On 08/14/14 at approximately 9:05AM, the cover to the smoke detector within Stair #8 at the 2nd Floor landing was noted on the floor.

e) On 08/14/14 at approximately 2:49PM, a cover plate to the junction box serving the smoke detector within Stair #6 at the Basement landing was noted to be missing.

f) On 08/15/14 at approximately 10:00AM, a smoke detector in Room #105 of the D Building was noted with a solid red light indicating a trouble signal.

In an interview on 08/13/14 at approximately 10:37AM, Staff #23 stated that corrective action will be taken as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.4.1, 9.6, NFPA 72-1999 National Fire Alarm Code: 7-1.1.1

10NYCRR, 405.24(b), 711.2(a)(1)
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Based on observation and interview, the facility failed to ensure that sprinkler coverage was provided in all required areas in that the Elevator Machine Room that serves the Emergency Department (ED) Elevator located in the Basement, and the 1st Floor Oncology Clinic located in the S Building lacked sprinkler coverage.

Findings:

From 08/14/14 through 08/15/14, between 9:00AM and 3:00PM, the Elevator Machine Room that serves the ED Elevator located in the Basement, and the 1st Floor Oncology Clinic located in the S Building lacked sprinkler coverage.

In an interview on 08/14/14 at approximately 2:45PM, Staff #24 stated that they would have the sprinklers added immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.5, 19.3.5.1, NFPA 13-1999
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2000 NFPA 101 LSC Chapter 19.3.5 Extinguishment Requirements 19.3.5.1
Where required by 19.1.6, Health Care Facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
9.7 AUTOMATIC SPRINKLERS AND OTHER EXTINGUISHING EQUIPMENT
9.7.2 Supervision
9.7.2.1* Supervisory Signals
Where supervised automatic sprinkler systems are required by another Section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.


Based on observation and interview, the facility failed to ensure that all sprinkler control valves were electronically supervised to sound an alarm at a continuously monitored location. This was evidenced by electronic supervisory devices noted not being provided on sprinkler control valves in-line of a sprinkler pipe located in Fan Room #3-2 on the 3rd Floor.

Findings:

On 08/14/14 at approximately 9:30AM, electronic supervisory devices were observed not provided on sprinkler control valves in-line of a sprinkler pipe located in Fan Room #3-2 on the 3rd Floor.

In an interview on 08/14/14 at this time, Staff #24 stated that they would have the company install the tamper switches immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 9.7.2.1, 19.3.5.1
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1998 NFPA 96- Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 7.2.2.1
Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer ' s instructions, and the following standards where applicable.
(1) NFPA 12, Standard on Carbon Dioxide Extinguishing Systems
(2) NFPA 13, Standard for the Installation of Sprinkler Systems
(3) NFPA 17, Standard for Dry Chemical Extinguishing Systems
(4) NFPA 17A, Standard for Wet Chemical Extinguishing Systems


1998 NFPA 17A- Standard for Wet Chemical Extinguishing Systems 5.2 Owner's Inspection 5.2.1
Inspection shall be conducted on a monthly basis in accordance with the manufacturer's listed installation and maintenance manual or the Owner's Manual. As a minimum, this "quick check" or inspection shall include verification of the following:
(1) The extinguishing system is in its proper location.
(2) The manual actuators are unobstructed.
(3) The tamper indicators and seals are intact.
(4) The maintenance tag or certificate is in place.
(5) No obvious physical damage or condition exists that might prevent operation.
(6) The pressure gauge(s), if provided, is in operable range.
(7) The nozzle blowoff caps are intact and undamaged.
(8) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.


Based on observation, interview and documentation review, the facility failed to ensure that the required monthly inspections of the range hood fire extinguishing system (ANSUL) in the kitchen were conducted.

Findings:

From 08/14/14 through 08/15/14, between 11:00AM and 3:00PM, the last documented ANSUL inspection was completed in June 2014 as noted by tags on the pull station and canisters in the 1st Floor Kitchen and Cafeteria. There were no documented monthly ANSUL inspections noted prior to and since the service date.

In an interview on 08/15/14 at approximately 2:30PM, Staff #24 stated that a monthly visual inspection was not being done and that they would start doing and documenting the monthly visual inspections.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.6, 9.2.3, 1998 NFPA 96: 7.2.2.1, 1998 NFPA 17A: 5.2.1
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1999 NFPA 99: 4-3.1.1.2(b) Additional Storage Requirements for Nonflammable Gases Greater than 3000 ft3 (85 m3)
3. The walls, floors, and ceilings of locations for supply systems of more than three thousand cubic feet (3000ft3) (85m3) total capacity (connected and in storage) separating the supply system location from other occupancies in a building shall have a fire resistance rating of at least one (1) hour. This shall also apply to a common wall or walls of a supply system location attached to a building having other occupancy.


Based on observation and interview, the facility failed to ensure that the main Oxygen Storage Room, located in the T Building and with stored capacity greater than 3000 cubic feet, was provided with a one (1) hour fire-rated enclosure in that the door was not provided with a self-closing device.

Findings:

On 08/15/14 at approximately 11:40AM, the main Oxygen Storage Room located in the T Building was observed with a stored capacity of greater than 3000 cubic feet of oxygen. The room was not provided with a one (1) hour fire-rated enclosure in that the door lacked a self-closing device.

In an interview at this time, Staff #24 stated that they would have a self-closing device installed immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.4, NFPA 99-1999: 4-3.1.1.2(b)3
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Based on review of documents and staff interview, the facility failed to maintain the Medical Gas System in compliance with NFPA 99.

Findings:

During the review of the Master Warning Alarm Findings Record of the Annual Medical Gas Inspection Report dated 06/23/14 conducted by Praxair, it was noted that the area warning alarm was found deficient.

The Zone Alarm Panel was marked as "Not Found" for Vacuum on the Ground Floor Facilities and the areas monitored were noted as E Building, D Building, DCB Building-4th Floor and DCB B3.

The condition of Area Warning Alarm for Oxygen in the area of the Dental Clinic in the Main Building was also noted as "Not Found" and the areas monitored included Rooms #308, #309, #310, #311 and #303. The same Report had similar defects for Nitrous Oxide and Vacuum on the same floor.

Similar findings were noted for Oxygen and Vacuum in the Recovery Nurses' Station, NICU (Neonatal Intensive Care Unit) and Endoscopy.

Review of the Inspection Report also revealed that the Oxygen, Vacuum, Medical Air and Nitrous Oxide in the OR (Operating Room) Nurses' Station (2nd Floor of DCB Building) were noted to be defective and the condition was labeled as "6", indicating "Pressure / Vac Indicator Defective". An "11" was noted against Nitrous Oxide indicating that it was "Not Electrically Powered".

An interview with Staff #24 on 08/15/14 at approximately 2:45PM confirmed that the Medical Gas System of the facility did not have zone alarms and that the system required an upgrade to be in compliance with NFPA 99.
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Based on observation, documentation (i.e., Panel Board Schedule) review and interview, 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 the 18th, 14th, 12th, 11th, 10th, 9th, 8th, 7th, 6th, 5th, 3rd and 2nd Floors.

Findings:

Examples include but are not limited to the following:

a) On 08/11/14 at approximately 12:00PM, review of the Emergency Power Panel Directory for Panel "17E3" in the 18th Floor East Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Corridor Lights) and Emergency System-Critical Branch Loads (e.g., Receptacles). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

b) On 08/12/14 at approximately 9:28AM, review of the Emergency Power Panel Directory for Panel "13E1 Section 2" in the 14th Floor West Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Fire Alarm) and Emergency System-Critical Branch Loads (e.g., Nurses' Call System). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

c) On 08/12/14 at approximately 10:10AM, review of the Emergency Power Panel Directory for Panel "12E2" in the 12th Floor North Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Fire Alarm Panels) and Emergency System-Critical Branch Loads (e.g., Elec. Clos. Toilets, Toilet Room). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

d) On 08/12/14 at approximately 11:18AM, review of the Emergency Power Panel Directory for Panel "11E3" in the 11th Floor East Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Corridor Lights) and Emergency System-Critical Branch Loads (e.g., Nurses' Station Receptacles). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

e) On 08/12/14 at approximately 11:48AM, review of the Emergency Power Panel Directory for Panel "10E1-2" in the 10th Floor West Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Fire Alarm Panel) and Emergency System-Critical Branch Loads (e.g., Receptacles). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

f) On 08/12/14 at approximately 2:00PM, review of the Emergency Power Panel Directory for Panel "9E2-1" in the 9th Floor North Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Fire Alarm Panels, Fire Dampers) and Emergency System-Critical Branch Loads (e.g., Receptacles). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

g) On 08/12/14 at approximately 2:50PM, review of the Emergency Power Panel Directory for Panel "8E1-2" in the 8th Floor West Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Fire Alarm Panel) and Emergency System-Critical Branch Loads (e.g., Nurses' Call System). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

h) On 08/13/14 at approximately 9:07AM, review of the Emergency Power Panel Directory for Panel "7E3" in the 7th Floor East Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Corridor Lights) and Emergency System-Critical Branch Loads (e.g., Nurses' Station Receptacles). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

i) On 08/13/14 at approximately 10:05AM, review of the Emergency Power Panel Directory for Panel "EES" in the 6th Floor East Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Corridor Lights, Exit Lights) and Emergency System-Critical Branch Loads (e.g., Nurses' Call System). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

j) On 08/13/14 at approximately 10:29AM, review of the Emergency Power Panel Directory for Panel "5E2" in the 5th Floor North Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Corridor Lights) and Emergency System-Critical Branch Loads (e.g., Receptacles). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

k) On 08/13/14 at approximately 11:30AM, review of the Emergency Power Panel Directory for Panel "3E5 Section #2" in the 3rd Floor East Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Corridor Lights, Exit Lights, Medical Gas Panel) and Emergency System-Critical Branch Loads (e.g., Receptacles, Pneumatic Tube System). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

l) On 8/13/14 at approximately 2:18PM, review of the Emergency Power Panel Directory for Panel "2E4 Section #8" in 2nd Floor Electrical Room #2230 revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Gas Alarms) and Emergency System-Critical Branch Loads (e.g., Receptacles, Pneumatic Tube Station). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 4.6.1.2, 19.5.1, 9.1.2, NFPA 99-1999 Standard for Health Care Facilities: 12-2.5, 12-3.3, 3-4.2.2, NFPA 70-1999 National Electrical Code: Article 517, Article 700-9, NFPA 76-1967, Essential Electrical Systems for Hospitals: Article 541 and NFPA 76A-1973, Essential Electrical Systems for Health Care Facilities: Article 551, NFPA 70-1965, National Electrical Code: Article 700-9, NFPA 70-1968, National Electrical Code: Article 700-9, NFPA 70-1971, National Electrical Code: Article 700-9

10NYCRR, 405.24(b), 711.2(a)(1), 711.2(a)(20)
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1) Based on observation and interview, the facility failed to ensure that at least one (1) outlet served by the Emergency System was provided at the bed location in the Post Anesthesia Care Unit (PACU).

Findings:

On 08/14/14 at approximately 10:00AM, the bed locations in the PACU were noted not provided with at least one (1) emergency outlet.

In an interview on 08/14/14 at this time, Staff #23 stated that they will notify Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 517-19


2) Based on observation and interview, the facility failed to ensure that flexible cords and cables were not used as a substitute for the fixed wiring of a structure. This was noted on the 7th and 2nd Floors and in the Basement.

Findings:

From 08/13/14 through 08/15/14, between 9:00AM and 3:00PM, the following was noted:

a) Relocatable power taps were noted in Operating Rooms (ORs) including, but not limited to, OR #11, OR #3 and OR #5.

b) A relocatable power tap was noted in the 7th Floor Staff Lounge.

c) An extension cord was noted in the Large Storage Room in the vicinity of the Laundry Room in the Basement.

During interview on 08/13/14 at approximately 2:45PM, Staff #23 stated that the facility may have to request a Waiver for the Operating Rooms.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-3, 400-8


3) Based on observation and interview, the facility failed to ensure that normal wiring was kept separate from emergency wiring. This was noted on the 3rd and 2nd Floors and in the Basement.

Findings:

From 08/13/14 through 08/15/14, between 9:00AM and 3:00PM, the following was noted:

a) A conduit was noted between Normal Power Panel "3N6" and Emergency Power Panel "3E6" in the 3rd Floor East Electrical Closet.

b) A conduit was noted between Normal Power Panel "2N3" and Emergency Power Panel "2E3A" in 2nd Floor Electrical Room #2230.

c) A conduit was noted between Normal Power Panel "BN3-2" and Emergency Power Panel "BE3" in Basement Electrical Room #B-243.

During interview on 08/14/14 at approximately 2:50PM, Staff #24 stated that the facility will address the issue immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 700-9


4) Based on observation and interview, the facility failed to ensure that all Emergency Power Panel Directories were provided with Panel Directories. This was noted on the 19th, 18th, 17th, 10th, 3rd, 2nd and Ground Floors.

Findings:

From 08/13/14 through 08/15/14 between 9:00AM and 3:00PM, the following missing Emergency Power Panel Directories were noted, including but not limited to:

a) 19th Floor North Electrical Room - Panel "17th Fl. EBST EIC".

b) 18th Floor North Electrical Room - Panel "17E2".

c) 17th Floor Mechanical Room - Sub Panel "16E3".

d) 10th Floor East Electrical Room - Panel "LP-9E3-PF".

e) 3rd Floor SE Electrical Room in the vicinity of Stair #9 - Panel "3E7".

f) 2nd Floor Electrical Room 2203 - New Emergency Panel.

g) Ground Floor Lab H840 - Emergency Panel.

In an interview on 08/13/14 at approximately 1:54PM, Staff #24 stated that the facility will check throughout the building and get updated Panel Directories.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 384-13


5) Based on observation and interview, the facility failed to ensure that all unprotected openings caused by missing circuit breakers were provided with blanks. This was noted on the 19th, 17th and 6th Floors.

From 08/13/14 through 08/15/14, between 9:00AM and 3:00PM, the following Power Panels were noted lacking blanks:

a) 19th Floor East Electrical Room - Panel "17th Fl. East EIC".

b) 17th Floor Mechanical Room - Panel "16E3".

c) 6th Floor North Electrical Room - Panel "6E2".

In an interview on 08/13/14 at approximately 9:21AM, Staff #24 stated that they will install the missing blanks.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-12


6) Based on observation and interview, the facility failed to ensure that Ground Fault Circuit Interrupters (GFCIs) were provided for hydrocollators. This was noted on the 5th and Ground Floors.

Findings:

From 08/13/14 through 08/15/14, between 9:00AM and 3:00PM, hydrocollators were noted plugged into normal outlets instead of GFCI outlets. Examples are:

a) 5th Floor Physical Therapy Room.

b) Ground Floor Occupational Therapy Room.

In an interview on 08/15/14 at approximately 11:25AM, Staff #24 stated that they would install the GFCI outlets immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code
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2000 NFPA 101: 9.4.6 Elevator Testing
Elevators shall be subject to routine and periodic inspections and tests as specified in ASME / ANSI A17.1, Safety Code for Elevators and Escalators. All elevators equipped with Fire Fighter Service in accordance with 9.4.4 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME / ANSI A17.1, Safety Code for Elevators and Escalators.


Based on observation, interview and documentation review, the facility failed to ensure that eleven (11) elevators equipped with Fire Fighter Service were tested for monthly operation with a written record of the findings made and kept on the premises.

Findings:

On 08/15/14 at approximately 2:40PM, a review of documentation was done in the presence of Staff #24. At the time of the survey, there was no documentation provided to indicate that the eleven (11) elevators equipped with Fire Fighter Service were tested for monthly operation.

In an interview on 08/15/14 at this time, Staff #24 stated that the facility will begin to document the monthly testing of the elevators.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 9.4.6
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Based on observation and interview, the facility failed to ensure that not more than ten (10) gallons are stored in a single smoke compartment outside a storage cabinet. This was noted in the General Storage Room in the Basement.

Findings:

On 08/14/14 at 2:35PM, approximately twenty-eight (28) gallons of alcohol based hand sanitizer (Ethyl Alcohol 62%) was noted being stored on the shelves and not within a storage cabinet in the General Storage Room in the Basement.

During interview on 08/14/14 at this time, Staff #24 stated that the facility will get a fire-rated cabinet to store the hand sanitizer.

CFR 403.744, 418.110, 460.72, 482.41, 483.70, 485.623

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1) Based on observation and interview, the facility failed to ensure that all corridor doors were provided with approved positive latching hardware. NFPA 101-2000 Life Safety Code Section 19.3.6.3.2 requires that corridor doors in Existing Health Care Occupancies be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction (e.g., doors shall be provided with positive latching hardware). Specific reference is made to the lack of positive latching hardware (e.g., automatic flush bolts).

Findings:

From 08/11/14 through 08/15/14, between 9:00AM and 3:00PM, the inactive leaf to two (2) sets of double doors on end rooms on the East and West Sides of the Dynamic Care Building (DCB) was found to be provided with concealed manually operated flush bolts that would take more than one (1) operation to secure in the event of a fire. This was noted on the 18th, 14th, 12th, 11th, 10th, 9th, 7th, 6th and 5th Floors and the Blood Donor Room on the Ground Floor.

In an interview on 08/12/14 at approximately 11:50AM, Staff #24 stated that they would have the manual flush bolts replaced with automatic flush bolts.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.3.2


2) Based on observation and interview, the facility failed to ensure that all corridor doors were provided with approved positive latching hardware. NFPA 101-2000 Life Safety Code Section 18.3.6.3.3 requires that there is no impediment to the closing of corridor doors in New Health Care Occupancies. If facility building plans were approved, or a building permit issued, or construction started after March 13, 2003, the building or addition must be surveyed under the 2000 New Health Care Occupancy Chapter. Specific reference is made to the sliding doors for the Treatment Rooms in the Emergency Department (ED) hanging up on the tracks, preventing them from positively latching.

Findings:

On 08/14/14 between 11:30AM and 12:15PM, the sliding doors for Treatment Rooms #7, #8 and #10 in the ED hung up on the tracks, preventing the corridor doors from positively latching.

In an interview on 08/14/14 at approximately 11:49AM, Staff #24 stated that they would have all of the Treatment Room doors checked and adjusted as necessary.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 18.3.6.3.3


3) Based on observation and interview, the facility failed to ensure that the undercut for corridor doors does not exceed one (1) inch. NFPA 101-2000 Life Safety Code Section 19.3.6.3.1 requires that the clearance between the bottom of the door and the floor covering does not exceed one (1) inch for corridor doors in Existing Health Care Occupancies. This was noted on the 14th Floor.

Findings:

On 08/12/14 between 9:35AM and 9:46AM, the clearance between the bottom of the door and the floor in Rooms #1454, #1455 and #1431 ranged from approximately one and one-quarter (1¼) inches to one and one-half (1½) inches.

In an interview on 08/12/14 at approximately 9:36AM, Staff #24 stated that they would have sweeps installed on the doors.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.3.1
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Based on observation and interview, the facility failed to ensure that plain glass vision panels that were installed as part of corridor doors on the 4th and 12th Floors shall be fixed window assemblies in approved frames. The rooms were located within partially sprinklered smoke compartments and there were no fire-rated labels on the glass and/or door assembly, contrary to the requirement that vision panels in corridor doors shall be fixed window assemblies in approved frames.

Findings:

On 08/12/14 between 9:00AM and 10:30PM, approximately thirty-four (34) inch by thirty (30) inch plain glass vision panels were installed as part of the corridor doors on the 12th and 14th Floors. Examples are Rooms #1244, #1243, #1441 and #1444.

The rooms were located in smoke compartments that were partially sprinklered (i.e. only the hazardous areas were provided with sprinkler coverage) and there were no fire-rated labels on the glass and/or door assembly.

In an interview on 08/12/14 at approximately 9:21AM, Staff #24 stated that they would make Administration aware of the issue.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.3.8
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2000 NFPA 101: 8.2.5.4*
The fire resistance rating for the enclosure of floor openings shall be not less than as follows (see 7.1.3.2.1 for enclosure of exits):
(1) Enclosures connecting four (4) stories or more in new construction - two (2) hour fire barriers.
(2) Other enclosures in new construction - one (1) hour fire barriers.
(3) Existing enclosures in existing buildings - one-half (½) hour fire barriers.
(4) As specified in Chapter 26 for lodging and rooming houses, in Chapter 28 for new hotels, and in Chapter 30 for new apartment buildings.


Based on observation and interview, the facility failed to ensure that the mechanical shaft in the vicinity of the Elevator Lobby on the 19th Floor was provided with a two (2) hour fire barrier.

Findings:

On 08/11/14 at approximately 10:45AM, the mechanical shaft in the vicinity of the Elevator Lobby on the 19th Floor was noted not provided with a two (2) hour fire barrier in that the door was not positively latching when tested and two (2) unsealed conduit penetrations were noted above the door to the shaft.

In an interview on 08/11/14 at this time, Staff #24 stated that the door would be fixed and the conduit penetrations would be sealed immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 8.2.5.4
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2000 NFPA 101: 19.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than one-half (½) hour.


Based on observation and interview, the facility failed to ensure that smoke barrier walls were constructed to have at least a one-half (½) hour fire resistance rating in that unsealed penetrations around wires and conduits, cut holes, improperly sealed, and unfinished wall assemblies were noted in smoke barrier walls on the 6th, 3rd, 2nd and 1st Floors.

Findings:

On 08/13/14 and 08/14/14, between 9:00AM and 3:00PM, unsealed penetrations around wires and conduits, cut holes, improperly sealed, and unfinished wall assemblies were noted in smoke barrier walls on the 6th, 3rd, 2nd and 1st Floors. Examples include but are not limited to the following:

a) 6th FLOOR:
i) Cable penetration within the Storage Room in the vicinity of the public Elevator Lobby.

ii) Multiple penetrations around pipe and conduit and an approximately three (3) inch diameter penetration around a sprinkler pipe in Clean Utility Room #621.

iii) Penetrations around conduit and between wires within conduit above the smoke barrier doors in the vicinity of Stair 2 in the North Corridor.

iv. Unsealed top-of-wall assembly above the smoke barrier doors in the South Corridor.

b) 3rd FLOOR:
i) Multiple penetrations within and around conduit above the smoke barrier doors in the vicinity of Stair #6.

ii) Multiple penetrations around wires and conduit above the smoke barrier doors in the vicinity of Room #3143.

iii) The Life Safety drawings provided by the facility indicate that the smoke barrier runs across two (2) open alcoves in the vicinity of Room #3309. Smoke barriers are continuous walls from outside to outside.

c) 2nd FLOOR:
i) Penetrations around a bundle of wires and within conduit above the smoke barrier doors in the Center Corridor to the ICU (Intensive Care Unit).

ii) Penetrations around conduit and wires in the electrical closet in the vicinity of Breast Imaging.

d) 1st FLOOR:
i. Approximately three (3) inch by three (3) inch and six (6) inch by six (6) inch square cut outs and a four (4) inch diameter penetration around a BX conduit above the smoke barrier doors to the ED (Emergency Department).

ii) An insulated pipe was sealed with joint compound and not an approved fire-stopping material in the Ultrasound Bathroom.


In an interview on 08/13/14 at approximately 9:39AM, Staff #24 stated that the penetrations would be sealed immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7.3, 8.3, 8.2.3
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2000 NFPA 101: 19.3.7.5
Openings in smoke barriers shall be protected by fire-rated glazing; by wired glass panels and steel frames; by substantial doors, such as one and three-quarter (1¾) inch (4.4cm) thick, solid-bonded wood core doors; or by construction that resists fire for not less than twenty (20) minutes. Nonrated factory - or field-applied protective plates extending not more than forty-eight (48) inches (122cm) above the bottom of the door shall be permitted.

Exception: Doors shall be permitted to have fixed fire window assemblies in accordance with 8.2.3.2.2.


1) Based on observation and interview, the facility failed to ensure that smoke barrier doors were provided with self-closing devices. This was noted on the 14th, 12th, 3rd and 2nd Floors.

Findings:

From 08/12/14 through 08/14/14, between 9:00AM and 3:00PM, doors to rooms that were part of the smoke barrier, as indicated by the facility's Life Safety Drawings, were not provided with self-closing devices. Examples are:

a) 14th Floor - Rooms #1428 and #1458.

b) 12th Floor - Rooms #1256 and #1230.

c) 3rd Floor - Storage Closet Room #3302.

d) 2nd Floor - Lounge Room #2141 and Conference Room #2348.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7.6

In an interview on 08/12/14 at approximately 9:30AM, Staff #24 stated that all of the smoke barrier walls would be re-evaluated in relation to the Life Safety Drawings.


2) Based on observation and interview, the facility failed to ensure that smoke barrier doors were constructed to resist fire for not less than twenty (20) minutes. This was noted on the 14th and 2nd Floors.

Findings:

From 08/12/14 through 8/14/14, between 9:00AM and 3:00PM, the following smoke barrier doors were not provided with labels or documentation to indicate construction that resists fire for not less than twenty (20) minutes. Examples are:

a) The door to Room #1417 on the South Corridor lacked a fire-rated label on the door or frame.

b) The door to the Respiratory Office on the 2nd Floor was noted with an approximately eighteen (18) inch by thirty-two (32) inch (five hundred seventy-six {576} square inches) plain glass vision panel. There was no fire-rated label on the glass or frame assembly.


In an interview on 08/14/14 at approximately 10:13AM, Staff #24 stated that the issues with the smoke barrier doors would be addressed.

2000 NFPA 101: 19.3.7.5
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1) Based on observation and interview, the facility failed to ensure that all door openings from hazardous areas were protected by self-closing, positive latching doors. This was noted on the 18th, 9th, 6th and 3rd Floors.

Findings:

a) From 08/11/14 through 08/14/14, between 9:00AM and 3:00PM, doors, when released, hit the frame and were not positively latching. Examples are:

i) 18th Floor Soiled Utility Room #1816.

ii) 9th Floor Soiled Utility Rooms #916 and #904.


b) From 08/11/14 through 8/14/14 between 9:00AM and 3:00PM, doors lacked a self-closing device. Examples are:

i) 6th Floor Storage Room in the vicinity of the public Elevator Lobby.

ii) Room #3117, which was being used for storage and was greater than fifty (50) square feet.


In an interview on 08/13/14 at approximately 11:55AM, Staff #24 stated that the doors would be fixed and that approved self-closing or automatic closing devices would be installed on all of the above-mentioned doors.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.1


2) Based on observation and interview, the facility failed to ensure that hazardous areas lacking sprinkler coverage were provided with one (1) hour fire rated construction with three-quarter (¾) hour fire-rated doors. This was noted on the 18th and 5th Floors.

Findings:

From 08/11/14 through 08/13/14, between 9:00AM and 3:00PM, hazardous areas lacking sprinkler coverage were not provided with one (1) hour fire rated construction with three-quarter (¾) hour fire-rated doors. Examples are:

a) The Storage Room on the 18th Floor adjacent to the Recreation Room lacked both sprinkler coverage and a fire-rated label on the door.

b) Storage Room #546 lacked both sprinkler coverage and a self-closing device. Additionally, the door had a twenty (20) minute fire-rated label instead of the required three-quarter (¾) hour fire-rating.


In an interview on 08/13/14 at approximately 10:41AM, Staff #24 stated that the facility will address the issues immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.1
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Based on observation and interview, the facility failed to ensure that exit enclosures (such as stairways) were enclosed with construction having a fire resistance rating of at least two (2) hours. This was noted on the 19th, 3rd and Ground Floors.

Findings:

From 08/11/14 through 08/15/14, between 9:00AM and 3:00PM, exit enclosures and exit passageways were not enclosed with construction having a fire resistance rating of at least two (2) hours and did not provide protection against fire or smoke from other parts of the building. Examples include:

a) An unsealed penetration was noted around a duct passing into the Psychiatric Emergency Department from the exit passageway from Stair #1 on the Ground Floor.

b) A broken self-closing device was noted on the "Old EMS (Emergency Medical Services) Break Room" within the exit passageway from Stair #6 on the Ground Floor.

c) An approximately six (6) inch diameter conduit was noted incorporated as part of the Stair #3 enclosure on the 3rd Floor.

d) Two (2) wire penetrations were noted above the door to Stair #2 on the 19th Floor.

In an interview on 08/15/14 at approximately 10:25AM, Staff #24 stated that all issues would be addressed immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 7.1.3.2, 8.2.5.2, 8.2.5.4, 19.3.1.1
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Based on observation and interview, the facility failed to ensure that exit access is so arranged that exits are readily accessible at all times in that two (2) Personal Care Aides (PCAs) on the 14th Floor were unaware which key unlocks the two (2) Exit Stair Doors.

Findings:

On 08/12/14 at approximately 9:45AM, two (2) PCAs on the 14th Floor Locked Unit were interviewed in the presence of the Director of Engineering and the Nurse Manager and were unaware as to which key unlocked the two (2) Exit Stair Doors.

In an interview on 08/12/14 at this time, the Nurse Manager stated that the staff would be re-inserviced immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 7.1, 19.2.1
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2000 NFPA 101: 7.10.1.3 Exit Stair Door Tactile Signage Tactile signage shall be located at each door into an exit stair enclosure, and such signage shall read as follows:
EXIT
Signage shall comply with CABO / ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, and shall be installed adjacent to the latch side of the door sixty (60) inches (152cm) above the finished floor to the centerline of the sign.


Based on observation and interview, the facility failed to ensure that exit stair door tactile signage was provided on the latch side of the door for stairs on the 6th, 3rd and 2nd Floors.

Findings:

From 08/13/14 through 08/14/14, between 9:00AM and 3:00PM, exit stair door tactile signage was not provided on the latch side of the door for two (2) of three (3) stairs in the building. Examples are:

a) 6th Floor - North Corridor Side for Stairs #2 and #3.

b) 3rd Floor - Stairs #1 and #6 and the South Corridor Side for Stair #3.

c) 2nd Floor - Stair #9.

In an interview on 08/14/14 at approximately 9:36AM, Staff #24 stated that they would have the tactile signs installed immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 7.10.1.3
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Based on observation and interview, the facility failed to ensure that fire alarm system initiating devices (e.g., smoke detectors) were properly maintained.

Findings:

a) On 08/11/14 at approximately 10:30AM, a smoke detector in the "Tele Health Room" on the 19th Floor was noted to be capped.

b) On 08/11/14 at approximately 10:55AM, a smoke detector in the West Electrical Room on the 19th Floor was noted to be capped.

c) On 8/13/14 at approximately 10:37AM, two (2) smoke detectors above patient beds in Room #550 were noted to be covered with duct tape.

d) On 08/14/14 at approximately 9:05AM, the cover to the smoke detector within Stair #8 at the 2nd Floor landing was noted on the floor.

e) On 08/14/14 at approximately 2:49PM, a cover plate to the junction box serving the smoke detector within Stair #6 at the Basement landing was noted to be missing.

f) On 08/15/14 at approximately 10:00AM, a smoke detector in Room #105 of the D Building was noted with a solid red light indicating a trouble signal.

In an interview on 08/13/14 at approximately 10:37AM, Staff #23 stated that corrective action will be taken as soon as possible.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.4.1, 9.6, NFPA 72-1999 National Fire Alarm Code: 7-1.1.1

10NYCRR, 405.24(b), 711.2(a)(1)
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Based on observation and interview, the facility failed to ensure that sprinkler coverage was provided in all required areas in that the Elevator Machine Room that serves the Emergency Department (ED) Elevator located in the Basement, and the 1st Floor Oncology Clinic located in the S Building lacked sprinkler coverage.

Findings:

From 08/14/14 through 08/15/14, between 9:00AM and 3:00PM, the Elevator Machine Room that serves the ED Elevator located in the Basement, and the 1st Floor Oncology Clinic located in the S Building lacked sprinkler coverage.

In an interview on 08/14/14 at approximately 2:45PM, Staff #24 stated that they would have the sprinklers added immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.5, 19.3.5.1, NFPA 13-1999
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2000 NFPA 101 LSC Chapter 19.3.5 Extinguishment Requirements 19.3.5.1
Where required by 19.1.6, Health Care Facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
9.7 AUTOMATIC SPRINKLERS AND OTHER EXTINGUISHING EQUIPMENT
9.7.2 Supervision
9.7.2.1* Supervisory Signals
Where supervised automatic sprinkler systems are required by another Section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.


Based on observation and interview, the facility failed to ensure that all sprinkler control valves were electronically supervised to sound an alarm at a continuously monitored location. This was evidenced by electronic supervisory devices noted not being provided on sprinkler control valves in-line of a sprinkler pipe located in Fan Room #3-2 on the 3rd Floor.

Findings:

On 08/14/14 at approximately 9:30AM, electronic supervisory devices were observed not provided on sprinkler control valves in-line of a sprinkler pipe located in Fan Room #3-2 on the 3rd Floor.

In an interview on 08/14/14 at this time, Staff #24 stated that they would have the company install the tamper switches immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 9.7.2.1, 19.3.5.1
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1998 NFPA 96- Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 7.2.2.1
Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer ' s instructions, and the following standards where applicable.
(1) NFPA 12, Standard on Carbon Dioxide Extinguishing Systems
(2) NFPA 13, Standard for the Installation of Sprinkler Systems
(3) NFPA 17, Standard for Dry Chemical Extinguishing Systems
(4) NFPA 17A, Standard for Wet Chemical Extinguishing Systems


1998 NFPA 17A- Standard for Wet Chemical Extinguishing Systems 5.2 Owner's Inspection 5.2.1
Inspection shall be conducted on a monthly basis in accordance with the manufacturer's listed installation and maintenance manual or the Owner's Manual. As a minimum, this "quick check" or inspection shall include verification of the following:
(1) The extinguishing system is in its proper location.
(2) The manual actuators are unobstructed.
(3) The tamper indicators and seals are intact.
(4) The maintenance tag or certificate is in place.
(5) No obvious physical damage or condition exists that might prevent operation.
(6) The pressure gauge(s), if provided, is in operable range.
(7) The nozzle blowoff caps are intact and undamaged.
(8) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.


Based on observation, interview and documentation review, the facility failed to ensure that the required monthly inspections of the range hood fire extinguishing system (ANSUL) in the kitchen were conducted.

Findings:

From 08/14/14 through 08/15/14, between 11:00AM and 3:00PM, the last documented ANSUL inspection was completed in June 2014 as noted by tags on the pull station and canisters in the 1st Floor Kitchen and Cafeteria. There were no documented monthly ANSUL inspections noted prior to and since the service date.

In an interview on 08/15/14 at approximately 2:30PM, Staff #24 stated that a monthly visual inspection was not being done and that they would start doing and documenting the monthly visual inspections.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.6, 9.2.3, 1998 NFPA 96: 7.2.2.1, 1998 NFPA 17A: 5.2.1
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1999 NFPA 99: 4-3.1.1.2(b) Additional Storage Requirements for Nonflammable Gases Greater than 3000 ft3 (85 m3)
3. The walls, floors, and ceilings of locations for supply systems of more than three thousand cubic feet (3000ft3) (85m3) total capacity (connected and in storage) separating the supply system location from other occupancies in a building shall have a fire resistance rating of at least one (1) hour. This shall also apply to a common wall or walls of a supply system location attached to a building having other occupancy.


Based on observation and interview, the facility failed to ensure that the main Oxygen Storage Room, located in the T Building and with stored capacity greater than 3000 cubic feet, was provided with a one (1) hour fire-rated enclosure in that the door was not provided with a self-closing device.

Findings:

On 08/15/14 at approximately 11:40AM, the main Oxygen Storage Room located in the T Building was observed with a stored capacity of greater than 3000 cubic feet of oxygen. The room was not provided with a one (1) hour fire-rated enclosure in that the door lacked a self-closing device.

In an interview at this time, Staff #24 stated that they would have a self-closing device installed immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.4, NFPA 99-1999: 4-3.1.1.2(b)3
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Based on review of documents and staff interview, the facility failed to maintain the Medical Gas System in compliance with NFPA 99.

Findings:

During the review of the Master Warning Alarm Findings Record of the Annual Medical Gas Inspection Report dated 06/23/14 conducted by Praxair, it was noted that the area warning alarm was found deficient.

The Zone Alarm Panel was marked as "Not Found" for Vacuum on the Ground Floor Facilities and the areas monitored were noted as E Building, D Building, DCB Building-4th Floor and DCB B3.

The condition of Area Warning Alarm for Oxygen in the area of the Dental Clinic in the Main Building was also noted as "Not Found" and the areas monitored included Rooms #308, #309, #310, #311 and #303. The same Report had similar defects for Nitrous Oxide and Vacuum on the same floor.

Similar findings were noted for Oxygen and Vacuum in the Recovery Nurses' Station, NICU (Neonatal Intensive Care Unit) and Endoscopy.

Review of the Inspection Report also revealed that the Oxygen, Vacuum, Medical Air and Nitrous Oxide in the OR (Operating Room) Nurses' Station (2nd Floor of DCB Building) were noted to be defective and the condition was labeled as "6", indicating "Pressure / Vac Indicator Defective". An "11" was noted against Nitrous Oxide indicating that it was "Not Electrically Powered".

An interview with Staff #24 on 08/15/14 at approximately 2:45PM confirmed that the Medical Gas System of the facility did not have zone alarms and that the system required an upgrade to be in compliance with NFPA 99.
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Based on observation, documentation (i.e., Panel Board Schedule) review and interview, 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 the 18th, 14th, 12th, 11th, 10th, 9th, 8th, 7th, 6th, 5th, 3rd and 2nd Floors.

Findings:

Examples include but are not limited to the following:

a) On 08/11/14 at approximately 12:00PM, review of the Emergency Power Panel Directory for Panel "17E3" in the 18th Floor East Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Corridor Lights) and Emergency System-Critical Branch Loads (e.g., Receptacles). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

b) On 08/12/14 at approximately 9:28AM, review of the Emergency Power Panel Directory for Panel "13E1 Section 2" in the 14th Floor West Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Fire Alarm) and Emergency System-Critical Branch Loads (e.g., Nurses' Call System). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

c) On 08/12/14 at approximately 10:10AM, review of the Emergency Power Panel Directory for Panel "12E2" in the 12th Floor North Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Fire Alarm Panels) and Emergency System-Critical Branch Loads (e.g., Elec. Clos. Toilets, Toilet Room). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

d) On 08/12/14 at approximately 11:18AM, review of the Emergency Power Panel Directory for Panel "11E3" in the 11th Floor East Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Corridor Lights) and Emergency System-Critical Branch Loads (e.g., Nurses' Station Receptacles). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

e) On 08/12/14 at approximately 11:48AM, review of the Emergency Power Panel Directory for Panel "10E1-2" in the 10th Floor West Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Fire Alarm Panel) and Emergency System-Critical Branch Loads (e.g., Receptacles). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

f) On 08/12/14 at approximately 2:00PM, review of the Emergency Power Panel Directory for Panel "9E2-1" in the 9th Floor North Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Fire Alarm Panels, Fire Dampers) and Emergency System-Critical Branch Loads (e.g., Receptacles). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

g) On 08/12/14 at approximately 2:50PM, review of the Emergency Power Panel Directory for Panel "8E1-2" in the 8th Floor West Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Fire Alarm Panel) and Emergency System-Critical Branch Loads (e.g., Nurses' Call System). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

h) On 08/13/14 at approximately 9:07AM, review of the Emergency Power Panel Directory for Panel "7E3" in the 7th Floor East Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Corridor Lights) and Emergency System-Critical Branch Loads (e.g., Nurses' Station Receptacles). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

i) On 08/13/14 at approximately 10:05AM, review of the Emergency Power Panel Directory for Panel "EES" in the 6th Floor East Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Corridor Lights, Exit Lights) and Emergency System-Critical Branch Loads (e.g., Nurses' Call System). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

j) On 08/13/14 at approximately 10:29AM, review of the Emergency Power Panel Directory for Panel "5E2" in the 5th Floor North Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Corridor Lights) and Emergency System-Critical Branch Loads (e.g., Receptacles). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

k) On 08/13/14 at approximately 11:30AM, review of the Emergency Power Panel Directory for Panel "3E5 Section #2" in the 3rd Floor East Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Corridor Lights, Exit Lights, Medical Gas Panel) and Emergency System-Critical Branch Loads (e.g., Receptacles, Pneumatic Tube System). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

l) On 8/13/14 at approximately 2:18PM, review of the Emergency Power Panel Directory for Panel "2E4 Section #8" in 2nd Floor Electrical Room #2230 revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Gas Alarms) and Emergency System-Critical Branch Loads (e.g., Receptacles, Pneumatic Tube Station). As per concurrent interview with Staff #24, they will notify facility Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 4.6.1.2, 19.5.1, 9.1.2, NFPA 99-1999 Standard for Health Care Facilities: 12-2.5, 12-3.3, 3-4.2.2, NFPA 70-1999 National Electrical Code: Article 517, Article 700-9, NFPA 76-1967, Essential Electrical Systems for Hospitals: Article 541 and NFPA 76A-1973, Essential Electrical Systems for Health Care Facilities: Article 551, NFPA 70-1965, National Electrical Code: Article 700-9, NFPA 70-1968, National Electrical Code: Article 700-9, NFPA 70-1971, National Electrical Code: Article 700-9

10NYCRR, 405.24(b), 711.2(a)(1), 711.2(a)(20)
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1) Based on observation and interview, the facility failed to ensure that at least one (1) outlet served by the Emergency System was provided at the bed location in the Post Anesthesia Care Unit (PACU).

Findings:

On 08/14/14 at approximately 10:00AM, the bed locations in the PACU were noted not provided with at least one (1) emergency outlet.

In an interview on 08/14/14 at this time, Staff #23 stated that they will notify Administration concerning this condition.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 517-19


2) Based on observation and interview, the facility failed to ensure that flexible cords and cables were not used as a substitute for the fixed wiring of a structure. This was noted on the 7th and 2nd Floors and in the Basement.

Findings:

From 08/13/14 through 08/15/14, between 9:00AM and 3:00PM, the following was noted:

a) Relocatable power taps were noted in Operating Rooms (ORs) including, but not limited to, OR #11, OR #3 and OR #5.

b) A relocatable power tap was noted in the 7th Floor Staff Lounge.

c) An extension cord was noted in the Large Storage Room in the vicinity of the Laundry Room in the Basement.

During interview on 08/13/14 at approximately 2:45PM, Staff #23 stated that the facility may have to request a Waiver for the Operating Rooms.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-3, 400-8


3) Based on observation and interview, the facility failed to ensure that normal wiring was kept separate from emergency wiring. This was noted on the 3rd and 2nd Floors and in the Basement.

Findings:

From 08/13/14 through 08/15/14, between 9:00AM and 3:00PM, the following was noted:

a) A conduit was noted between Normal Power Panel "3N6" and Emergency Power Panel "3E6" in the 3rd Floor East Electrical Closet.

b) A conduit was noted between Normal Power Panel "2N3" and Emergency Power Panel "2E3A" in 2nd Floor Electrical Room #2230.

c) A conduit was noted between Normal Power Panel "BN3-2" and Emergency Power Panel "BE3" in Basement Electrical Room #B-243.

During interview on 08/14/14 at approximately 2:50PM, Staff #24 stated that the facility will address the issue immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 700-9


4) Based on observation and interview, the facility failed to ensure that all Emergency Power Panel Directories were provided with Panel Directories. This was noted on the 19th, 18th, 17th, 10th, 3rd, 2nd and Ground Floors.

Findings:

From 08/13/14 through 08/15/14 between 9:00AM and 3:00PM, the following missing Emergency Power Panel Directories were noted, including but not limited to:

a) 19th Floor North Electrical Room - Panel "17th Fl. EBST EIC".

b) 18th Floor North Electrical Room - Panel "17E2".

c) 17th Floor Mechanical Room - Sub Panel "16E3".

d) 10th Floor East Electrical Room - Panel "LP-9E3-PF".

e) 3rd Floor SE Electrical Room in the vicinity of Stair #9 - Panel "3E7".

f) 2nd Floor Electrical Room 2203 - New Emergency Panel.

g) Ground Floor Lab H840 - Emergency Panel.

In an interview on 08/13/14 at approximately 1:54PM, Staff #24 stated that the facility will check throughout the building and get updated Panel Directories.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 384-13


5) Based on observation and interview, the facility failed to ensure that all unprotected openings caused by missing circuit breakers were provided with blanks. This was noted on the 19th, 17th and 6th Floors.

From 08/13/14 through 08/15/14, between 9:00AM and 3:00PM, the following Power Panels were noted lacking blanks:

a) 19th Floor East Electrical Room - Panel "17th Fl. East EIC".

b) 17th Floor Mechanical Room - Panel "16E3".

c) 6th Floor North Electrical Room - Panel "6E2".

In an interview on 08/13/14 at approximately 9:21AM, Staff #24 stated that they will install the missing blanks.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-12


6) Based on observation and interview, the facility failed to ensure that Ground Fault Circuit Interrupters (GFCIs) were provided for hydrocollators. This was noted on the 5th and Ground Floors.

Findings:

From 08/13/14 through 08/15/14, between 9:00AM and 3:00PM, hydrocollators were noted plugged into normal outlets instead of GFCI outlets. Examples are:

a) 5th Floor Physical Therapy Room.

b) Ground Floor Occupational Therapy Room.

In an interview on 08/15/14 at approximately 11:25AM, Staff #24 stated that they would install the GFCI outlets immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code
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2000 NFPA 101: 9.4.6 Elevator Testing
Elevators shall be subject to routine and periodic inspections and tests as specified in ASME / ANSI A17.1, Safety Code for Elevators and Escalators. All elevators equipped with Fire Fighter Service in accordance with 9.4.4 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME / ANSI A17.1, Safety Code for Elevators and Escalators.


Based on observation, interview and documentation review, the facility failed to ensure that eleven (11) elevators equipped with Fire Fighter Service were tested for monthly operation with a written record of the findings made and kept on the premises.

Findings:

On 08/15/14 at approximately 2:40PM, a review of documentation was done in the presence of Staff #24. At the time of the survey, there was no documentation provided to indicate that the eleven (11) elevators equipped with Fire Fighter Service were tested for monthly operation.

In an interview on 08/15/14 at this time, Staff #24 stated that the facility will begin to document the monthly testing of the elevators.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 9.4.6
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