HospitalInspections.org

Based on observations and staff interview, the 2 hour and 3 hour fire-rated non-conforming building common walls were not maintained.

The findings are:

1) On the morning of 1/10/2012, observation of the 2 hour fire-rated common wall separating the Taylor Care building and the Main building revealed that an unknown type of spray foam sealant was used to fill a penetration over the doors. Multiple pipe penetrations were also found over these doors.

2) On the morning of 1/11/2012, observation of the 3 hour fire-rated common wall separating the Main Hospital and Maria Fareri Children's Hospital on the 1st. floor revealed that there were penetrations and other issues found. Specifically:

a) A penetration from an old magnetic door lock "power" wire was found above the 3 hour fire-rated doors.

b) Multiple penetrations were found on the 3 hour fire-rated doors where the metal plates for the old magnetic locks once were. When these metal plates were removed the screw penetrations were never sealed.

c) The gap at the bottom of the fire-rated doors were greater then a 1/2".

d) The fire-rated doors were not positively latching.

Concurrent interview with Staff #14 at the times of the observation confirmed these findings.

Based on observations during survey of the Main Hospital, it was noted that structural components of the facility were not properly protected from fire. Structural steel/steel beams located above the non-fire rated ceiling assembly were not protected to meet requirements for minimum fire rated building construction of Type II 222.

Findings include:

During tour observations of the facility from 01/09/12 to 01/13/12 between 11:00 AM to 4:00 PM, observations revealed that the I-beams and steel beams/steel web truss assemblies/steel supporting the weight of the deck above were not completely protected with a fire resistive material. Also, some I-beams were missing the fire resistive material in parts where hanging elements/accessories were installed.

Some examples, including but not limited to, missing fire resistive material are the I-beams in Electrical closets in the 5th, 1st and 7th floor of the Main Hospital.

Findings were verified with Staff #12

2000 NFPA 101: 19.1.6.2, 19.3.5.1, 4.6.6, 19.1.1.4.1
1999 NFPA 220: 3-1

Based on observations and staff interview, the facility did not ensure that all vertical shafts were enclosed with 1 hour fire-rated construction.

The findings are:

1) On the morning of 1/09/2012, observation of Electrical Switchboard room (LLL03) revealed a 2"vertical pipe penetration in the ceiling.

2) On the afternoon of 1/09/2012, observation of the 1 hour rated corridor in the basement level of the Main building revealed two dumbwaiter penetrations. Specifically:

A 6" x 4" rectangular penetration was found above an existing non-functioning dumb-waiter. Multiple data wires were found running through this penetration.

The glass on the dumb-waiter was also cracked and broken. Therefore, the 1 hour fire-rated access door to the dumb-waiter was not maintained.

3) On the afternoon of 1/09/2012, observation in Room 0377 revealed:
That there was a 4' x 4' square hole found in the corner of the room that was partially covered with multiple layers of sheetmetal and wood.

Two of the 1 hour fire-rated access panels located on the ceiling were missing.

Concurrent interview with Staff #14 at the time of the observation confirmed these findings.

Based on observations and staff interview, the doors within the hazardous areas, and the 1 hour fire-rated smoke barrier were not maintained.

The finding are:

On the morning of 1/10/2012, observation revealed that:

1) The Fire Door in the Storage Room of the Central Supply Room was propped open by a 5 gal. container of bleach solution. This door had a label on it which stated "Fire Door - Please Keep Closed".

2) Both of the 45 minute fire-rated doors for the Carpenters Shop and Construction Shop had manual door stoppers located at the bottom of the doors.

3) The 45 minute fire-rated doors for rooms OER 11 and OER 16 were propped open with miscellaneous. supplies (i.e. old doors, miscellaneous. pieces of wood, etc.)

Interview with Staff #14 at the times of the observation confirmed these findings.

Based on observation and staff interview, the doors for the smoke barrier separation were not maintained.

The finding is:

On the afternoon of 1/11/2012, observation of the closing of the smoke doors separating corridors C3201 and C3301 revealed that they do not close flush together when activated. These doors must be adjusted to ensure complete closure.

Concurrent interview with Staff #14 at the time of the observation confirmed this finding.

Ahsan, Novaira I.
Based on observation, staff interview and document review, the facility did not comply with the NFPA 241 code, to construct and maintain the temporary hazard area partition and integrity of the fire/smoke walls. This was noted for the hazard partition of the areas that are under construction in the facility.

Findings include:

1.(a) During the tour of the facility on 01/09/12 at 3:30 PM, it was noted that there were unsealed holes and wires/conduits penetrating the wall that separates the ORs in the main building from the ORs under renovation in that area.

1.(b) As per NFPA 241, Standard for Safeguarding Construction, Alteration, and Demolition Operations, 2000 Edition:
8.6.2 Temporary Separation Walls.
8.6.2.1 Protection shall be provided to separate an occupied portion of the structure from a portion of the structure undergoing alteration, construction, or demolition operations when such operations are considered as having a higher level of hazard than the occupied portion of the building.
8.6.2.2 Walls shall have at least a 1-hour fire resistance rating.
8.6.2.3 Opening protectives shall have at least a 45-minute fire protection rating.
8.6.2.4 Non-rated walls and opening protectives shall be permitted when an approved automatic sprinkler system is installed.
A8.6.2.4 Construction tarps would NOT be considered appropriate barrier or opening protectives.

2. During the tour of the Radiology suite on 01/13/12 at 2:00 PM, it was noted that the temporary barrier separating the under construction areas in the Radiology suite were not completely sealed to divide the under operational areas from construction areas, thus preventing fire hazards. The barrier exhibited about 2x2 foot gap above the suspended sealing near the entrance to the construction area.

All above findings were verified with Staff #12 .

3. During review of the ILSM sheet posted on the site and policy of 'Westchester Medical Center: Process Entry Report, Construction Guidelines", it was noted that bullet #5 states that one of the requirements is 'Seal holes, pipes, conduits and punctures appropriately'. Furthermore bullet #3 states that 'Complete all critical barriers or implement control cube method before construction begins'. As per the above referenced code all barriers should be one-hour rated and maintained in for its integrity which was not seen during the survey in the facility.

Staff #2 stated that all construction started before he joined the facility; therefore, he is not aware of why the partitions were not built as required.


27522

Based on observations and staff interview, the 1 hour fire-rated construction of the Main building and the Macy building was not maintained.

The findings are:

1) On the morning of 1/09/2012, observations in the basement level of the Main building revealed that:

a) In Mechanical Room (LLL04) :
A 2' x 2' square cut out was found in the 1 hour fire-rated wall.
An unknown spray foam sealant was used around a pipe penetration of 1 hour f-re-rated wall.
The existing lock holes in the access doors to the Electrical Switchboard room (LLL03) were not sealed when the existing locking mechanism was removed.

b) In Central Distribution Area there was a partially sealed HVAC duct. This duct appeared to be damaged/banged into.

3) On the afternoon of 1/09/2012, observations in the basement level of the Main building revealed that:
A dry rag was plugging a penetration within the 1 hour fire-rated wall of room 0477.

An unknown spray foam sealant was used to seal the penetration around a junction box located in the 1 hour fire-rated corridor wall in the vicinity of room 0463.

A 1' x 1' square punch out was found in the corridor wall opposite room 0465.

A 6" x 12" rectangular hole was found within a 1 hour fire-rated wall of room 0377.

4) On the morning of 1/10/2012, observations of the Macy building basement level revealed that:
An unknown spray foam sealant was used to seal the head of the wall in room 0161.

Two penetrations were found over the access door to the Soiled Utility Room.

Two data wire penetrations were found in the Carpenters Shop. This room is a hazardous area and must be properly sealed.

There were multiple penetrations (i.e. BX cables, electrical conduits, sprinkler pipe, etc.) found in the Hilron Cleaning Room.

There was no 45 minute fire-rated door found for room OER 09.

A penetration caused by a bundle of fire alarm BX cables were found over the door entering the Biomedical Mechanical Space.

5) On the afternoon of 1/10/2012, observations in the first floor of the Main building revealed that:
A penetration caused by five fire alarm BX cables were found in the 1 hour fire-rated wall of the Pre-Admitting Testing Area.

The data wire sleeve found in the Clinical Lab west corridor 1 hour fire-rated wall was not sealed.

The 45 minute fire-rated doors for 1H68A and 1H68B did not have self closures on them.

Concurrent staff interview with Staff # during these observations confirmed these findings.

Based on staff interview and record review, the Main building of the hospital does not have the required means of egress. Specifically, the facility does not have vertical exits directly to the outside of the building.

The finding is:

On 1/12/2012, record review and concurrent interview with staff #14, revealed and confirmed that a non-operational waiver request for the 1997 NFPA 101 (i.e. the Life Safety Code) "Means of Egress - Discharge from Exits" was submitted to CMS on June 21, 2010. The staff member also stated that this waiver has not yet been approved or denied by CMS. Therefore this constitutes as a federal Life Safety Code deficiency, and will be identified as one until the issue is resolved by the hospital and CMS.

Based on observations and staff interview, the 2 hour fire resistance rating for the emergency exit stairway walls were not maintained.

The findings are:

On the morning of 1/11/2012, observation in emergency exit stairway #10 and #9 revealed that there were penetrations within the 2 hour fire-rated wall construction. Specifically:

a) On the first floor level of stairway #10, support beams for the sprinkler line were penetrating the fire-rated wall.

b) On the first floor level of stairway #9, a 6" standpipe was penetrating the fire-rated walls.

Concurrent interview with Staff #14 at the times of the observation confirmed these findings.

Based on observation, facility failed to keep the corridor serving as an exit access in the Endoscopy Suite clear and unobstructed and at least feet in width.

Findings include

During the tour of the Endoscopy Suit in the Main Hospital on 01/13/12 at 12:15 Pm, it was noted that there were three stretchers in the corridor that may be used as exit access in case of emergency. The width of the corridor is very narrow. The clear width of the corridor was barely 4 feet or less. This arrangement may impede in emergency evacuation of patients.

Findings were verified with Staff #12 and Staff #15.

Based on document review and staff interview, the facility did not ensure that the fire drills were conducted under varying conditions and that planning/ evaluation of fire drills were done as per NFPA 101.

Findings include:

1. During fire drill record review on 01/13/12 at 2:45 PM, it was noted that the fire drill report is in the form of a checklist which is incomplete, highlighting only a few points of the drill on which the 'observer' of the drill checks off "yes" or "no".

2. Review of fire drill records indicated that although the hospital's fire drills include transmission of a fire alarm signal, the hospital failed to conduct fire drills which include simulation of various types of emergency fire conditions to ensure that each staff has a full and clear understanding of facility's fire safety plan and how to execute it successfully under the varying conditions.

Staff #16 confirmed these findings.

3. Although the facility's fire drill records included staff sign-in sheets, the facility failed to document in the records a critique of the drill, staff's fire drill response and staff knowledge of evacuation procedure to ensure staff is fully aware of fire drill/evacuation protocols .
Staff #16 stated that there were no other records to document the fire drill procedures and comments on them.

Section 8-2* of NFPA 96 states that:
An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

Based on document review and staff interview, the facility did not conduct semi-annual inspections on the exhaust hoods of the cooking appliances in the kitchen as required by the code.

Findings include:

On 01/11/12 at 11:30 AM, Staff # 15 provided the surveyor with the exhaust hood inspection reports from August 2010 and August 2011. Surveyor requested for the semi-annual reports too.

01/13/12 at 1:50 PM, surveyor again requested the reports from Staff # 16. Later Staff # 16 stated there were no semi-annual reports as the vendor was not performing it for the facility.

Based on observation and staff interview, the facility failed to ensure that the artificial decorative plants displayed in the facility are not constructed of combustible material, unless otherwise rendered flame retardant.

The findings include:

During the survey from 01/09/12 to 01/13/12 between 1:00 AM to 4:00 PM, it was observed that the facility had provided decorative artificial plants about 4.0-5.0 feet tall in various areas of the Main Hospital building. An interview with Staff #12 at the time of observations revealed that he could not confirm the non-combustible nature or the flame-retardant properties of these artificial trees. He stated that he did not think that those plants were rendered flame retardant by any chemical treatment.

Based on observation, the facility did not ensure that all trash collection receptacles with capabilities greater than 32 gallons are located in a room protected as a hazardous area when not attended. The carts used to store and transport garbage were noted stored in the alcove near elevators.

Findings include:

On 01/10/12 0 at 2:00 PM, at least two large garbage containers greater than 32 gallon were noted stored unattended on the 2nd floor Taylor Building in the elevator alcove/room in proximity of the B2 unit. These were unattended.

Staff #12 acknowledged that all soiled linen/trash bags/containers, when not attended, are to be stored in soiled utility room of the respective floors or in the main soiled holding room in the basement which are enclosed with a minimum of 1 hour fire resistance rated construction.

Based on record review and staff interview, the facility did not ensure that the piped in medical gas system's discrepancies were corrected in a timely manner and as per NFPA 99.

Findings include:

On 01/10/12 at 3:30 PM during the review of the medical gas report of the facility from 'Praxair' dated September 2011, it was noted that the report indicated many repair deficiencies, leaks, flow failure and master alarm connection deficiencies. No follow up report was provided indicating if these deficiencies were corrected. Furthermore, there were some valves marked not tested/or valves unavailable. Staff #12 could not provide a response whether these valves were checked on a later date or were completely overlooked.

Findings were confirmed with Staff #12.

Based on document review and staff interview, it was determined that the facility performs general anesthesia and has emergency generators installed in the facility and thus has a Type I EES (essential electrical system). The wiring of the electrical system at the panels on patient care floors in the Main building are not in compliance with the code . NFPA 99 3-4.

Findings include:

1. In an interview with Staff #15 on 01/12/12 at 11:15 AM, Staff #15 suggested that the wiring configuration in the facility for the Type I EES is not in compliance with 1999 NFPA 99 3-4.2.2.1. The specific issue involved was that the separation of the generator branches into a life safety, critical, and equipment system was done for the generators but the panels on patient floors were not provided segregating the three branches. Thus the panels have mixed wiring for life safety, critical and equipment branch in whatever panel is present on the patient floor. or the facility.
The facility operates a ventilator dependent unit, and as such, requires a Type I EES.

Document review of the panel and switches also revealed that the wiring for items required to be served by the Equipment System was not independent from wiring for items required to be served by the Emergency System, and the wiring for items required to be served by the Emergency System - Life Safety Branch was not independent from wiring for items required to be served by the Emergency System - Critical Branch.

1999 NFPA 99 3-4.2.1.4, 3-4.2.2, NFPA 70: Article 517 and Article 700.

2. Facility had identified the issue during a State pre-opening survey for the Labor and Delivery Unit. Facility had submitted a waiver to State Agency identifying the issue. However there were no approvals, waivers or correspondence to CMS (Center for Medicare & Medicaid Services) indicating that this configuration is acceptable or regarding any time frame when the facility plans to comply with the code.

Based on observation and staff interview, the facility's electrical wiring and equipment was not maintained in accordance with NFPA 70.

The findings are:

1) During the course of the survey from 1/09/2012 to 1/13/2012, multiple locations where electrical panels were partially or totally inaccessible. Specifically:

a) On the morning of 1/09/2012, observation of room LLC03 (i.e. the Central Distribution Area) revealed that a security panel was inaccessible. There was a storage cart with two stacked boxes blocking access to the panel.

b) On the morning of 1/09/2012, observation of rooms LLL04A and LLL04B revealed that there was no access to Emergency Panel E-16, or the other types of panels (i.e. equipment panels, transformer disconnects, etc.). It was blocked by miscellaneous equipment (i.e. broken electrical panels on floor, spools of wire, etc.). All the panels in these rooms were also missing the assigned panel sheets.

c) On the afternoon of 1/09/2012, observation of room 0477 revealed that inside an inaccessible closet was an active transformer for Panel P-EM.

d) On the morning of 1/10/2012, observation in the Carpenters Shop revealed that a electrical panel and a disconnect switch was inaccessible.

2) On the morning of 1/10/2012, observation in the basement level of the Main building corridors revealed that temporary wiring and temporary plastic light cages were found along the entire corridor B-BC01.

3) On the morning of 1/13/2012, observation of the medical equipment located in the specified Article 28 clinical space of the Bradhurst Center revealed that this equipment was plugged into non-hospital grade outlets. This equipment must be plugged into a hospital grade outlet. Specific equipment examples include the posturing equipment, the medical bikes, the patient tables, etc.

Concurrent interview with Staff #14 at the times of the observation confirmed these findings.

Based on observations and staff interview, the 2 hour and 3 hour fire-rated non-conforming building common walls were not maintained.

The findings are:

1) On the morning of 1/10/2012, observation of the 2 hour fire-rated common wall separating the Taylor Care building and the Main building revealed that an unknown type of spray foam sealant was used to fill a penetration over the doors. Multiple pipe penetrations were also found over these doors.

2) On the morning of 1/11/2012, observation of the 3 hour fire-rated common wall separating the Main Hospital and Maria Fareri Children's Hospital on the 1st. floor revealed that there were penetrations and other issues found. Specifically:

a) A penetration from an old magnetic door lock "power" wire was found above the 3 hour fire-rated doors.

b) Multiple penetrations were found on the 3 hour fire-rated doors where the metal plates for the old magnetic locks once were. When these metal plates were removed the screw penetrations were never sealed.

c) The gap at the bottom of the fire-rated doors were greater then a 1/2".

d) The fire-rated doors were not positively latching.

Concurrent interview with Staff #14 at the times of the observation confirmed these findings.

Based on observations during survey of the Main Hospital, it was noted that structural components of the facility were not properly protected from fire. Structural steel/steel beams located above the non-fire rated ceiling assembly were not protected to meet requirements for minimum fire rated building construction of Type II 222.

Findings include:

During tour observations of the facility from 01/09/12 to 01/13/12 between 11:00 AM to 4:00 PM, observations revealed that the I-beams and steel beams/steel web truss assemblies/steel supporting the weight of the deck above were not completely protected with a fire resistive material. Also, some I-beams were missing the fire resistive material in parts where hanging elements/accessories were installed.

Some examples, including but not limited to, missing fire resistive material are the I-beams in Electrical closets in the 5th, 1st and 7th floor of the Main Hospital.

Findings were verified with Staff #12

2000 NFPA 101: 19.1.6.2, 19.3.5.1, 4.6.6, 19.1.1.4.1
1999 NFPA 220: 3-1

Based on observations and staff interview, the facility did not ensure that all vertical shafts were enclosed with 1 hour fire-rated construction.

The findings are:

1) On the morning of 1/09/2012, observation of Electrical Switchboard room (LLL03) revealed a 2"vertical pipe penetration in the ceiling.

2) On the afternoon of 1/09/2012, observation of the 1 hour rated corridor in the basement level of the Main building revealed two dumbwaiter penetrations. Specifically:

A 6" x 4" rectangular penetration was found above an existing non-functioning dumb-waiter. Multiple data wires were found running through this penetration.

The glass on the dumb-waiter was also cracked and broken. Therefore, the 1 hour fire-rated access door to the dumb-waiter was not maintained.

3) On the afternoon of 1/09/2012, observation in Room 0377 revealed:
That there was a 4' x 4' square hole found in the corner of the room that was partially covered with multiple layers of sheetmetal and wood.

Two of the 1 hour fire-rated access panels located on the ceiling were missing.

Concurrent interview with Staff #14 at the time of the observation confirmed these findings.

Based on observations and staff interview, the doors within the hazardous areas, and the 1 hour fire-rated smoke barrier were not maintained.

The finding are:

On the morning of 1/10/2012, observation revealed that:

1) The Fire Door in the Storage Room of the Central Supply Room was propped open by a 5 gal. container of bleach solution. This door had a label on it which stated "Fire Door - Please Keep Closed".

2) Both of the 45 minute fire-rated doors for the Carpenters Shop and Construction Shop had manual door stoppers located at the bottom of the doors.

3) The 45 minute fire-rated doors for rooms OER 11 and OER 16 were propped open with miscellaneous. supplies (i.e. old doors, miscellaneous. pieces of wood, etc.)

Interview with Staff #14 at the times of the observation confirmed these findings.

Based on observation and staff interview, the doors for the smoke barrier separation were not maintained.

The finding is:

On the afternoon of 1/11/2012, observation of the closing of the smoke doors separating corridors C3201 and C3301 revealed that they do not close flush together when activated. These doors must be adjusted to ensure complete closure.

Concurrent interview with Staff #14 at the time of the observation confirmed this finding.

Ahsan, Novaira I.
Based on observation, staff interview and document review, the facility did not comply with the NFPA 241 code, to construct and maintain the temporary hazard area partition and integrity of the fire/smoke walls. This was noted for the hazard partition of the areas that are under construction in the facility.

Findings include:

1.(a) During the tour of the facility on 01/09/12 at 3:30 PM, it was noted that there were unsealed holes and wires/conduits penetrating the wall that separates the ORs in the main building from the ORs under renovation in that area.

1.(b) As per NFPA 241, Standard for Safeguarding Construction, Alteration, and Demolition Operations, 2000 Edition:
8.6.2 Temporary Separation Walls.
8.6.2.1 Protection shall be provided to separate an occupied portion of the structure from a portion of the structure undergoing alteration, construction, or demolition operations when such operations are considered as having a higher level of hazard than the occupied portion of the building.
8.6.2.2 Walls shall have at least a 1-hour fire resistance rating.
8.6.2.3 Opening protectives shall have at least a 45-minute fire protection rating.
8.6.2.4 Non-rated walls and opening protectives shall be permitted when an approved automatic sprinkler system is installed.
A8.6.2.4 Construction tarps would NOT be considered appropriate barrier or opening protectives.

2. During the tour of the Radiology suite on 01/13/12 at 2:00 PM, it was noted that the temporary barrier separating the under construction areas in the Radiology suite were not completely sealed to divide the under operational areas from construction areas, thus preventing fire hazards. The barrier exhibited about 2x2 foot gap above the suspended sealing near the entrance to the construction area.

All above findings were verified with Staff #12 .

3. During review of the ILSM sheet posted on the site and policy of 'Westchester Medical Center: Process Entry Report, Construction Guidelines", it was noted that bullet #5 states that one of the requirements is 'Seal holes, pipes, conduits and punctures appropriately'. Furthermore bullet #3 states that 'Complete all critical barriers or implement control cube method before construction begins'. As per the above referenced code all barriers should be one-hour rated and maintained in for its integrity which was not seen during the survey in the facility.

Staff #2 stated that all construction started before he joined the facility; therefore, he is not aware of why the partitions were not built as required.


27522

Based on observations and staff interview, the 1 hour fire-rated construction of the Main building and the Macy building was not maintained.

The findings are:

1) On the morning of 1/09/2012, observations in the basement level of the Main building revealed that:

a) In Mechanical Room (LLL04) :
A 2' x 2' square cut out was found in the 1 hour fire-rated wall.
An unknown spray foam sealant was used around a pipe penetration of 1 hour f-re-rated wall.
The existing lock holes in the access doors to the Electrical Switchboard room (LLL03) were not sealed when the existing locking mechanism was removed.

b) In Central Distribution Area there was a partially sealed HVAC duct. This duct appeared to be damaged/banged into.

3) On the afternoon of 1/09/2012, observations in the basement level of the Main building revealed that:
A dry rag was plugging a penetration within the 1 hour fire-rated wall of room 0477.

An unknown spray foam sealant was used to seal the penetration around a junction box located in the 1 hour fire-rated corridor wall in the vicinity of room 0463.

A 1' x 1' square punch out was found in the corridor wall opposite room 0465.

A 6" x 12" rectangular hole was found within a 1 hour fire-rated wall of room 0377.

4) On the morning of 1/10/2012, observations of the Macy building basement level revealed that:
An unknown spray foam sealant was used to seal the head of the wall in room 0161.

Two penetrations were found over the access door to the Soiled Utility Room.

Two data wire penetrations were found in the Carpenters Shop. This room is a hazardous area and must be properly sealed.

There were multiple penetrations (i.e. BX cables, electrical conduits, sprinkler pipe, etc.) found in the Hilron Cleaning Room.

There was no 45 minute fire-rated door found for room OER 09.

A penetration caused by a bundle of fire alarm BX cables were found over the door entering the Biomedical Mechanical Space.

5) On the afternoon of 1/10/2012, observations in the first floor of the Main building revealed that:
A penetration caused by five fire alarm BX cables were found in the 1 hour fire-rated wall of the Pre-Admitting Testing Area.

The data wire sleeve found in the Clinical Lab west corridor 1 hour fire-rated wall was not sealed.

The 45 minute fire-rated doors for 1H68A and 1H68B did not have self closures on them.

Concurrent staff interview with Staff # during these observations confirmed these findings.

Based on staff interview and record review, the Main building of the hospital does not have the required means of egress. Specifically, the facility does not have vertical exits directly to the outside of the building.

The finding is:

On 1/12/2012, record review and concurrent interview with staff #14, revealed and confirmed that a non-operational waiver request for the 1997 NFPA 101 (i.e. the Life Safety Code) "Means of Egress - Discharge from Exits" was submitted to CMS on June 21, 2010. The staff member also stated that this waiver has not yet been approved or denied by CMS. Therefore this constitutes as a federal Life Safety Code deficiency, and will be identified as one until the issue is resolved by the hospital and CMS.

Based on observations and staff interview, the 2 hour fire resistance rating for the emergency exit stairway walls were not maintained.

The findings are:

On the morning of 1/11/2012, observation in emergency exit stairway #10 and #9 revealed that there were penetrations within the 2 hour fire-rated wall construction. Specifically:

a) On the first floor level of stairway #10, support beams for the sprinkler line were penetrating the fire-rated wall.

b) On the first floor level of stairway #9, a 6" standpipe was penetrating the fire-rated walls.

Concurrent interview with Staff #14 at the times of the observation confirmed these findings.

Based on observation, facility failed to keep the corridor serving as an exit access in the Endoscopy Suite clear and unobstructed and at least feet in width.

Findings include

During the tour of the Endoscopy Suit in the Main Hospital on 01/13/12 at 12:15 Pm, it was noted that there were three stretchers in the corridor that may be used as exit access in case of emergency. The width of the corridor is very narrow. The clear width of the corridor was barely 4 feet or less. This arrangement may impede in emergency evacuation of patients.

Findings were verified with Staff #12 and Staff #15.

Based on document review and staff interview, the facility did not ensure that the fire drills were conducted under varying conditions and that planning/ evaluation of fire drills were done as per NFPA 101.

Findings include:

1. During fire drill record review on 01/13/12 at 2:45 PM, it was noted that the fire drill report is in the form of a checklist which is incomplete, highlighting only a few points of the drill on which the 'observer' of the drill checks off "yes" or "no".

2. Review of fire drill records indicated that although the hospital's fire drills include transmission of a fire alarm signal, the hospital failed to conduct fire drills which include simulation of various types of emergency fire conditions to ensure that each staff has a full and clear understanding of facility's fire safety plan and how to execute it successfully under the varying conditions.

Staff #16 confirmed these findings.

3. Although the facility's fire drill records included staff sign-in sheets, the facility failed to document in the records a critique of the drill, staff's fire drill response and staff knowledge of evacuation procedure to ensure staff is fully aware of fire drill/evacuation protocols .
Staff #16 stated that there were no other records to document the fire drill procedures and comments on them.

Section 8-2* of NFPA 96 states that:
An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

Based on document review and staff interview, the facility did not conduct semi-annual inspections on the exhaust hoods of the cooking appliances in the kitchen as required by the code.

Findings include:

On 01/11/12 at 11:30 AM, Staff # 15 provided the surveyor with the exhaust hood inspection reports from August 2010 and August 2011. Surveyor requested for the semi-annual reports too.

01/13/12 at 1:50 PM, surveyor again requested the reports from Staff # 16. Later Staff # 16 stated there were no semi-annual reports as the vendor was not performing it for the facility.

Based on observation and staff interview, the facility failed to ensure that the artificial decorative plants displayed in the facility are not constructed of combustible material, unless otherwise rendered flame retardant.

The findings include:

During the survey from 01/09/12 to 01/13/12 between 1:00 AM to 4:00 PM, it was observed that the facility had provided decorative artificial plants about 4.0-5.0 feet tall in various areas of the Main Hospital building. An interview with Staff #12 at the time of observations revealed that he could not confirm the non-combustible nature or the flame-retardant properties of these artificial trees. He stated that he did not think that those plants were rendered flame retardant by any chemical treatment.

Based on observation, the facility did not ensure that all trash collection receptacles with capabilities greater than 32 gallons are located in a room protected as a hazardous area when not attended. The carts used to store and transport garbage were noted stored in the alcove near elevators.

Findings include:

On 01/10/12 0 at 2:00 PM, at least two large garbage containers greater than 32 gallon were noted stored unattended on the 2nd floor Taylor Building in the elevator alcove/room in proximity of the B2 unit. These were unattended.

Staff #12 acknowledged that all soiled linen/trash bags/containers, when not attended, are to be stored in soiled utility room of the respective floors or in the main soiled holding room in the basement which are enclosed with a minimum of 1 hour fire resistance rated construction.

Based on record review and staff interview, the facility did not ensure that the piped in medical gas system's discrepancies were corrected in a timely manner and as per NFPA 99.

Findings include:

On 01/10/12 at 3:30 PM during the review of the medical gas report of the facility from 'Praxair' dated September 2011, it was noted that the report indicated many repair deficiencies, leaks, flow failure and master alarm connection deficiencies. No follow up report was provided indicating if these deficiencies were corrected. Furthermore, there were some valves marked not tested/or valves unavailable. Staff #12 could not provide a response whether these valves were checked on a later date or were completely overlooked.

Findings were confirmed with Staff #12.

Based on document review and staff interview, it was determined that the facility performs general anesthesia and has emergency generators installed in the facility and thus has a Type I EES (essential electrical system). The wiring of the electrical system at the panels on patient care floors in the Main building are not in compliance with the code . NFPA 99 3-4.

Findings include:

1. In an interview with Staff #15 on 01/12/12 at 11:15 AM, Staff #15 suggested that the wiring configuration in the facility for the Type I EES is not in compliance with 1999 NFPA 99 3-4.2.2.1. The specific issue involved was that the separation of the generator branches into a life safety, critical, and equipment system was done for the generators but the panels on patient floors were not provided segregating the three branches. Thus the panels have mixed wiring for life safety, critical and equipment branch in whatever panel is present on the patient floor. or the facility.
The facility operates a ventilator dependent unit, and as such, requires a Type I EES.

Document review of the panel and switches also revealed that the wiring for items required to be served by the Equipment System was not independent from wiring for items required to be served by the Emergency System, and the wiring for items required to be served by the Emergency System - Life Safety Branch was not independent from wiring for items required to be served by the Emergency System - Critical Branch.

1999 NFPA 99 3-4.2.1.4, 3-4.2.2, NFPA 70: Article 517 and Article 700.

2. Facility had identified the issue during a State pre-opening survey for the Labor and Delivery Unit. Facility had submitted a waiver to State Agency identifying the issue. However there were no approvals, waivers or correspondence to CMS (Center for Medicare & Medicaid Services) indicating that this configuration is acceptable or regarding any time frame when the facility plans to comply with the code.

Based on observation and staff interview, the facility's electrical wiring and equipment was not maintained in accordance with NFPA 70.

The findings are:

1) During the course of the survey from 1/09/2012 to 1/13/2012, multiple locations where electrical panels were partially or totally inaccessible. Specifically:

a) On the morning of 1/09/2012, observation of room LLC03 (i.e. the Central Distribution Area) revealed that a security panel was inaccessible. There was a storage cart with two stacked boxes blocking access to the panel.

b) On the morning of 1/09/2012, observation of rooms LLL04A and LLL04B revealed that there was no access to Emergency Panel E-16, or the other types of panels (i.e. equipment panels, transformer disconnects, etc.). It was blocked by miscellaneous equipment (i.e. broken electrical panels on floor, spools of wire, etc.). All the panels in these rooms were also missing the assigned panel sheets.

c) On the afternoon of 1/09/2012, observation of room 0477 revealed that inside an inaccessible closet was an active transformer for Panel P-EM.

d) On the morning of 1/10/2012, observation in the Carpenters Shop revealed that a electrical panel and a disconnect switch was inaccessible.

2) On the morning of 1/10/2012, observation in the basement level of the Main building corridors revealed that temporary wiring and temporary plastic light cages were found along the entire corridor B-BC01.

3) On the morning of 1/13/2012, observation of the medical equipment located in the specified Article 28 clinical space of the Bradhurst Center revealed that this equipment was plugged into non-hospital grade outlets. This equipment must be plugged into a hospital grade outlet. Specific equipment examples include the posturing equipment, the medical bikes, the patient tables, etc.

Concurrent interview with Staff #14 at the times of the observation confirmed these findings.