HospitalInspections.org

Based upon observations, interviews, and review of the facility's policy and procedures and other facility documents, it was determined that the facility failed to:
1) implement a fully functioning infant protection security system ; 2) maintain facilities in good repair; 3) maintain proper infection control due to airborne isolation room penetrations; 4) comply with life safety code requirements for prevention of fire; and 5) comply with Federal and State regulations for Americans with Disabilities accessibility requirements.

Findings include:

1. The facility failed to ensure that the security systems (e.g., infant abduction prevention system) were designed to adequately ensure the safety of infants from abduction.
(See Tag A701).

2. The facility failed to ensure that all furnishings and fixtures in the facility building were maintained in good repair and/or a clean condition.
(See Tag A 701)

3. The facility failed to ensure that walls that enclose designated Airborne Infection Isolation Rooms were sealed to prevent air from infiltrating the environment from the outside or from other spaces
(See Tag A 701)

4. The facility failed to meet Life Safety Code standards (See Tag A710).

5. The facility failed to meet all accessibility requirements (See Tag A722)

Based on observation, staff interview and review of procedures, it was determined the facility failed to: 1) implement an infant electronic security system with tamper resistant features; 2) maintain facilities in good repair; and 3) prevent cross contamination from penetrations identified in airborne isolation rooms.


Finding #1 includes:


During the tour on the 4th Floor of the Pediatric Unit on 05/27/2015, it was stated by the Director of Security at 8:45 AM that an electronic tag system is used to augment safety and tracking of newborn infants on 4th floor of the hospital. This system operates when an electronic transponder tag is attached to a band placed around the ankle of all infants placed under the monitoring system.

During observed testing of this system on the morning of 05/27/2015 it was noted that the band does not have any tamper resistant features and if the band was removed out of the alarm sensor range (e.g., in a patient room), that it would be possible for someone to take an infant out of the unit, through the exit door or elevator, without any alarm sounding.

On 05/27/2015 at 8:55 AM, the facility 's Director of Security, Director of Environmental Health and Safety, and maternity unit nursing supervisor were informed that due to the lack of any kind of tamper resistant features in the band, that it could be possible to defeat the facility' s current infant abduction prevention system and abduct an infant. The facility ' s Director of Security, Director of Environmental Health and Safety, and maternity unit nursing supervisor all acknowledged the finding.



Finding #2 includes:


a). On 05/22/15 at 11:11 AM, a heavy build-up of dust was noted on the table in room 445 (the vicinity of the shower area on the 4th floor). It was also observed that the handle of one of the drawers of one (1) of the table in the room was missing.

b). On 05/22/15 at 1:50 PM, the handle of a drawer in the patient room 503 on the 5th floor was missing.

c). On 05/26/15 at 8:48 AM, the wooden handrail in the vicinity of room 412 on the 4th floor was in a state of disrepair, having chipped surfaces with exposed projecting nail.

d). On 05/26/15 at 11:10 AM, one (1) exterior glass window in the Microbiology laboratory on the 2nd floor was observed to be cracked.

e). On 05/26/15 at 2:20 PM, the wall area of the accessory stairs in the basement of the Hospital was covered with mold- like growths and was in a state of disrepair with multiple peeling paints.

f). On 05/27/15 at 8:00 AM, the lower outer finished side of the door leading to the Administrative corridor area in the first floor was noted to be in disrepair (delaminating / peeling off of door surface).

42CFR482.41 (a)


Finding #3 includes:


On 05/26/15 at 9:25 AM, two unsealed conduit penetrations and a cable penetration were noted in an enclosed wall of a designated Airborne Infection Isolation Room shared by Room 443-2 and room 443-1 on the 4th floor. The facility therefore did not ensure that walls that enclose designated Airborne Infection Isolation Rooms were sealed to prevent air from infiltrating the environment from the outside or from other spaces.


42CFR482.41 (a)

Based on observations and interviews, the hospital did not ensure that the Life Safety from fire requirements are met.

Findings include:

See Life Safety Code survey deficiencies in the 2567 form for Event ID # HRYF21, recorded under tag #s K12,K17, K20, K25, K27, K29, K33, K34, K46, K48,K62, K64, K69, K76, K104, K130, K145, K147, and K211.
42 CFR 482.41(b)
K12 - The facility failed to ensure that the building containing healthcare occupancy that were of Type II(000) Unprotected, Noncombustible Construction were limited to only two (2) stories in height and were provided with complete automatic sprinkler protection.

K17 - The facility failed to ensure that corridor walls form a barrier to prevent the transfer of smoke.

K20 - The facility failed to ensure that all vertical penetrations of fire barriers were enclosed with construction having at least a one (1) hour resistance rating.

K25 - The facility failed to ensure that existing smoke barrier walls were properly constructed and that penetrations of these walls were properly sealed.

K27 - The facility failed to ensure that smoke barrier doors were self-closing.

K29 - The facility failed to ensure that all newly constructed hazardous areas were enclosed with at least a one (1) hour fire resistance rated walls and are protected by self-closing positive latching doors.

K33 -The facility failed to ensure that exit stair enclosures were properly constructed and that penetrations of these walls were properly sealed.

K34 -The facility failed to ensure that not normally occupied rooms (e.g., mechanical equipment rooms) did not open directly into exit stair enclosures, that wiring from systems or equipment that did not serve exit stair enclosures were not run into exit stair enclosures, and that exit stairs were maintained in good repair.

K46 - The facility failed to provide emergency illumination for not less than 1½ hours in the event of failure of normal lighting.

K48 - The facility failed to ensure the protection of all persons in the event of a fire and for their evacuation to areas of refuge.

K62 - The facility failed to ensure that all fire sprinklers and associated components were maintained in good repair, properly installed, and free of foreign materials.

K64 -The facility failed to ensure that portable fire extinguishers were installed in accordance with the requirements found in NFPA 10, Standard for Portable Fire Extinguishers.

K69 - The facility failed to ensure that the required placards were placed near each portable fire extinguisher in cooking areas.

K76 -The facility did not ensure that electrical fixtures in oxygen storage locations were mounted at least 60- inches above the finished floor as a precaution against their physical damage and that vehicles did not park any closer than 10-feet from exposed piping at the bulk oxygen storage location or that NO PARKING signs were properly installed or maintained.

K104 -The the facility failed to ensure that penetrations of smoke barriers by ducts are protected in accordance with NFPA 101 Life Safety Code Section 8.3.5.

K130 - The facility failed to ensure that the safety of the building containing the healthcare occupancy was not compromised by the placement of non-fire resistance rated combustible structures less than 10-feet from unprotected windows, that buildings that containing atriums were fully sprinklered and that other requirements for buildings containing atriums were met, that the integrity of fire barriers were maintained, that the arrangements of all means of egress in the hospital were in accordance with NFPA 101-2000 Section 19.2.5, that doors in a means of egress were operable with not more than one releasing operation, and that Ambulatory health care facilities were separated from other tenants and occupancies by walls having not less than a 1-hour fire resistance rating.

K145 - The facility was not provided with a Type I Essential Electrical System that was divided into separate Critical Branch, Life Safety Branch and Equipment Systems.

K147 - The facility failed to ensure that electrical wiring was installed and maintained in good repair.

K211 - The facility failed to ensure that not alcohol based hand sanitizer are not used in carpeted areas that lack sprinkler protection that not more than 10 gallons of alcohol based hand sanitizer are stored in a single smoke compartment outside a storage cabinet.

Based on observation and staff interviews, the Facility failed to: 1) provide accessibility signage as required by the Americans with Disabilities Act (ADA) and 2) comply with design requirements due to lack of access aisle as required by State regulations and ADA.

The findings include, but are not limited to, the following examples:
1. On 05/22/15 at 2:10 PM, the visitor ' s bathroom in the vicinity of the Diabetics Conference Room on the 5th floor lacked appropriate Americans with Disability Act (ADA) signage. The facility ' s Director of Environmental Health and Safety acknowledged the finding.


10NYCRR, 711.2 (c). Design standards for the disabled. The Americans with Disabilities Act of 1990 (ADA) extends comprehensive civil rights protection to persons with disabilities. Health Care Facilities must comply with the ADA and the regulations which implement it. Title 28 of the Code of Federal Regulations, Public Health Parts 35, Non-Discrimination on the Basis of Disability in State and Local Government Services, and Part 36, Non-Discrimination on the Basis of Disability by Public Accommodations and in Commercial Facilities, including Appendix A, "Standard for Accessible Design", 2004 Edition. 28 CFR Part 36 ADA Standards for Accessible Design: 4.1.2(6), 4.30.7(1)



2. On 05/22/15 at 8:00AM, ten (10) out of fifteen (15) parking spaces located at the Main Entrance to the Hospital that were designated, by signage, as being accessible, were found to lack an access aisle. Access aisles that are at least 60-inches wide are required to serve each accessible parking space (please note that one {1} access aisle can be shared by two {2} parking spaces). As per interview with the Facility's Director of Engineering on 05/22/15 at 9:00 AM, he acknowledged this finding and said that the parking lot would be redesigned as soon as possible

10NYCRR, 711.2 (c). Design standards for the disabled. The Americans with Disabilities Act of 1990 (ADA) extends comprehensive civil rights protection to persons with disabilities. Health Care Facilities must comply with the ADA and the regulations which implement it. Title 28 of the Code of Federal Regulations, Public Health Parts 35, Non-Discrimination on the Basis of Disability in State and Local Government Services, and Part 36, Non-Discrimination on the Basis of Disability by Public Accommodations and in Commercial Facilities, including Appendix A, "Standard for Accessible Design", 2004 Edition. 28 CFR Part 36 ADA Standards for Accessible Design: 4.6.