HospitalInspections.org

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Based on observation and staff interview, the facility failed to ensure that hazardous areas are protected by a fire barrier having one (1) hour fire resistance rating (with three-quarter {¾} hour rated doors) or an automatic fire extinguishing system in accordance with 8.7.1.

Findings:

On 08/21/17 at 1:26PM a hole, approximately two (2) inches wide was observed in the Equipment Storage Room in the Operating Room. An interview with Staff R confirmed this finding on 08/21/17 at approximately 1:30PM.

On 08/22/17 at 11:31AM it was observed that the Storage Room by the corridor of the business occupancy on the Ground Floor which was not sprinkler protected lacked a one (1) hour fire resistive enclosure. There was a cable penetration of the room and no self-closing device on the door. An interview with Staff R on 08/22/17 at approximately 11:35AM confirmed these findings.

On 08/22/17 at 10:4 AM it was observed that the facility converted a Dressing Cubicle Radiology Suite to a Storage Room without properly upgrading this space into a Storage Room. Specifically, the wall of the room / cubicle did not go up to the ceiling and there is no self-closing device on the door and there is no sprinkler system. A concurrent interview with Staff Members R and S on 08/22/17 at approximately 10:45AM confirmed this finding.
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Based on observation and staff interview, the facility failed to ensure that automatic sprinkler systems were inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-Based Fire Protection Systems.

Findings:

On 08/23/17 at 11:52AM it was observed that the concealed sprinkler head in Ground Floor Stair K lacked an escutcheon cover plate. An interview with Staff S on 08/23/17 at 11:53AM confirmed this finding.

On 08/23/17 at 2:02PM, it was observed that the concealed sprinkler system in the Electrical Closet in the facility extension clinic located at 3 Technology Drive, Suite 400 lacked an escutcheon cover plate. A concurrent interview conducted with Staff Q on 08/23/17 at approximately 2:10PM confirmed this finding.

On 08/23/17 at 2:24PM it was observed that the facility did not ensure that two (2) spares of every sprinkler head installed in the facility are in the spare sprinkler box as required. Specifically, the facility had eight (8) upright spare sprinkler heads in the spare sprinkler box located in the Automatic Sprinkler Room. A concurrent interview with Staff Q on 08/23/17 at 2:24PM confirmed this finding.

On 08/25/17 at 10:56PM it was observed that there was no battery back-up light in the facility Fire Pump Room as required. A concurrent interview conducted on 08/25/17 at approximately 11:00AM with Staff S confirmed this finding.
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Based on observation and staff interview, the facility failed to ensure that electrical wiring and equipment complies with NFPA 70, National Electric Code.

Findings:

On 08/21/17 at 11:40AM it was observed that the electrical panel inside the electrical closet in the vicinity of the Emergency Department on the Ground Floor had no label. A concurrent interview conducted on 08/21/17at approximately 11:45AM with Staff R confirmed this finding.

On 08/21/17 at 2:32PM it was observed that electrical panel inside the Operating Room Storage Room on the Ground Floor lacked a label. An interview with Staff R on 08/21/17 at 2:33PM confirmed this finding.

On 08/22/17 at 11:21AM it was observed that the electrical panel in the vicinity of the Bone Density Laboratory lacked a panel identification label. Also, the unidentified panel had two (2) blank holes in the panel. A concurrent interview with Staff R on 07/22/17 at 11:21AM confirmed these findings.

On 08/21/17 at 11:20AM an open electrical junction box was observed above the ceiling in the vicinity of the exit corridor to the facility's ASC vestibule. A concurrent interview with Staff R confirmed this finding.

On 08/22/17 at 12:13PM it was observed that two (2) electrical closet in the vicinity of the Laboratory on the Ground Floor lacked a panel identification label. A concurrent interview with Staff R confirmed these findings.

On 08/23/17 at 11:43AM it was observed that two (2) electrical panels in the Detox Suite in the 2 North Building lacked a panel identification label and a panel directory. An interview with Staff Members Q and R on 08/23/17 at 11:43AM confirmed these findings.

On 08/23/17 at 1:56PM it was observed that one (1) electrical panel in the facility extension clinic at 3 Technology Drive, Suite 400, East Setauket, NY 11733, lacked a panel identification label. A concurrent interview with Staff Q confirmed this finding.
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Based on observation and staff interview, the facility failed to ensure that mobile soiled linen or trash collection receptacles shall not exceed thirty-two (32) gallons in capacity and shall be located in a room protected as a Hazardous Area when not attended 18.7.5.7, 19.7.5.7.

Findings:

On 08/21/17 at 11:56AM it was observed that the facility stored a large linen cart (with clean linen), approximately 250 cubic feet, in an open space (alcove) in the vicinity of the Emergency Department and the Intensive Care Unit. A concurrent interview conducted on 08/21/17 at approximately 12:00 noon with Staff Members R and S confirmed this finding.

On 08/23/17 at 11:05AM it was observed that facility stored one (1) large mobile soiled linen container (with soiled linen and trash), approximately 367 gallons, and one (1) large mobile waste container, approximately 200 gallons, in an open space (alcove) in the vicinity of the Labor and Delivery Suite. A concurrent interview with Staff Members R and S on 08/23/17 at approximately 11:10AM confirmed these findings.
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Based on observations and staff interview, the facility did not install local alarm panels in all Critical Care Areas.

Findings:

During the tour of the 4th Floor of the North Building on 08/25/17 at approximately 11:30AM, the Surveyor observed the Hemodialysis Treatment Area with two (2) Stations located in Room #488. Both stations were observed to be equipped with piped-in oxygen and suction. However, the facility did not have an area and local alarm panel to monitor the pressure of oxygen and suction.

This observation was made in the presence of the Life Safety Director, Staff R and this Staff Member on 08/25/17 at approximately 12:45PM confirmed that there was no alarm panel installed for this area.
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Based on record review and staff interview, the facility did not maintain and test the Line Isolation Monitors (LIM) installed in the Operating Room Suite.

Findings:

During review of documents on 08/24/17 at approximately 12:00 noon, it was revealed that the facility did not have documented evidence of any maintenance and testing performed on the Line Isolation Monitors installed outside the Operating Rooms.

The facility's Plant Supervisor, Staff T, upon interview on 08/24/17 at approximately 2:00PM, stated that the facility did not perform periodic testing on the LIMs. It was also stated that repairs were conducted when an alarm was activated. The facility did not document the repairs either.
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Based on observation, documentation review and interview: (a) the facility's North Building (except for the 2nd Floor) did not have a Type 1 Essential Electrical System (EES), (b) the EES Distribution in the East and South Buildings were not separated into Critical Branch, Life Safety Branch and Equipment Branches in accordance with NFPA 99. This was noted during review of the electrical distribution panels located in the North, East and South Buildings.

Findings include:

During the tour of the facility during the survey dates of 08/21/17 - 08/25/17, review of the Electrical Panel Directories served by the emergency generators revealed the following:

(a) On 08/22/17 at approximately 11:00AM review of the load distribution in Emergency Electrical Panel "EE" located on the Ground Floor of the North Building, revealed that the panel served devices on all three (3) branches (Life Safety Branch, Critical Branch and Equipment Branch). The Panel Directory revealed that the panel served emergency power to Exit Lights, Pathology Equipment and Condensate Pumps. Interview with the Plant Supervisor, Staff R, revealed that the emergency power to this panel was served from the Generator installed in the North Building, which had only two (2) transfer switches and was not a Type 1 EES System.

Interview with the Director of Facilities, Staff S, revealed that the facility had received a Time Limited Waiver (TLW) to perform the required electrical work to provide a Type 1 EES System in the North Building.

(b) Review of the electrical panels served by emergency power in the East and South Buildings revealed that the two (2) buildings had the required three (3) branches of a Type 1 EES System. However, the devices were not appropriately connected to the correct branch of the EES System.

Examples include but not limited to:

(1) On 08/23/17 at approximately 2:30PM, review of the load distribution in Emergency Electrical Panel "BES" located in the Switch Gear Room of the South Building, revealed that the panel served the Life Safety Branch (e.g. Corridor Lights, Exit Lights, Stairwell Lights) and the Critical Branch (e.g. Sterilizer, Sterilizer UPS).

(2) On 08/24/17 at approximately 12:00 noon, review of the load distribution in Emergency Electrical Panel "ELL-MCC_BEQ" located in the Basement of the East Building revealed that the panel served the Life Safety Branch (Elevator Lights), the Equipment Branch (e.g. Hot Water Pumps, Hot Water Circulator) and Critical Branch (e.g. Med Air Dryers).

These observations were confirmed with the facility's Plant Supervisor, Staff T, on 08/24/17 at approximately 2:30PM.

Upon interview with the Life Safety Director, Staff R, on 08/24/17 at approximately 3:00PM, it was stated that the facility will re-assess the distribution of emergency power for the Essential Electrical System in the East and South Buildings while in the process of wiring the North Building to comply with a Type 1 EES System.