HospitalInspections.org

Life Safety code section 19.3.3.2 requires that interior finishes including moveable walls/partitions be in compliance with Section 10.2.3.Section10.2.3.1 requires that interior finishes be in compliance with NFPA 255, Standard method Test of all surfaces Burning Characteristics of building Materials.

Based on observation, staff interview and documentation review, the facility did not ensure all interior finishes for flame spread rating in rooms or spaces not used as corridor have a flame spread rating of class A or B. Specific reference is made to the fact that the facility failed to ensure that the flame retardancy of the 100% polyester cubicle curtains is maintained after they are repeatedly laundered and /or dry cleaned.

Findings include:

During the tour of the central stores on 08/28/14 at approximately 10:30 AM, the surveyors observed that the laundered cubicle curtains were being stored on racks. It was noted that these cubicle curtains did not have the flame spread rating on them or on the package.

During the review of the manufacturer's Fire Tests report on the flame propagation revealed that the manufacturer certified that the cubicle curtain "passes" testing process "initially". According to the same document, the manufacturer requires that the material be tested and certified for flame propagation "After 3 dry cleanings" and "After 5 launderings @160 F".

Upon interview of employee #15, on 08/28/14, at approximately 11:00 AM, it was revealed that the facility did not track the number of launderings and dry cleanings on each cubicle curtain and did not send the material for testing after being laundered and/or dry cleaned. Therefore the facility failed to ensure the flame spread rating of the cubicle curtains were within NFPA 101 specifications of Class A or Class B.

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 observed in smoke barrier walls in the basement and on the 5th and 8th Floors.

Findings:

On 08/28/14, 09/02/14 and 09/04/14, between 9:00 AM and 3:00 PM, unsealed penetrations around wires and conduits, cut holes, improperly sealed, and unfinished wall assemblies were observed in smoke barrier walls in the basement, 5th floor and 8th Floor.

Examples include, but are not limited to the following:


In the basement electrical closet BA11 multiple penetrations around galvanized pipe and conduit and an approximately three (3) inch diameter penetration.

Penetrations around unsealed conduit in the electrical closet 5B-18

Penetrations around two unsealed telecommunication cable conduits above the smoke barrier wall in room 8B-845

Tour of the soiled utility room on 8th Floor revealed that the wall between the soiled utility and clean utility room was unfinished and there was a gap of an inch identified between the wall and the ceiling.

Interview of Employee #2, revealed that the facility staff were sealing the penetrations with firestopping as and when they were being identified.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7.3, 8.3, 8.2.3

Based on observation and interview, the facility failed to ensure that exit access is so arranged that exits are readily accessible at all times.

Findings:

On 08/28/14 at approximately 10:00 AM, the exit from Emergency room to the Ambulance Bay was blocked by 3 Stretcher beds.

In an interview on 08/28/14 at 10:00 AM, employee #4 stated that a storage space for these extra stretcher beds would be identified.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 7.1, 19.2.1

2000 NFPA 101 Life Safety code 9.6.3.2 require that Occupant Notification shall be provided by audible and visible signals.

American Disability Act requires the provision of visible notification devices in conjunction with audible alarms in occupied areas.

Based on observation and staff interview, the facility failed to comply with Life Safety Code and ADA recommendations. Specific reference is made to the audiology clinic, where patients hard of hearing are diagnosed and treated.

Findings include:

During the tour of the audiology clinic located on 6 south of the main building, on 09/09/14 at approximately 2:30 PM, it was noted that the audiology clinic and audiology testing booth did not have the strobes for visible fire alarm notification in case of a fire emergency.

Interview of employee #2 on 09/09/14 concurrently, it was stated that the facility will contact the fire alarm company to install strobes in the clinic as quickly as possible.

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 various locations throughout the building.

Findings:

On 08/28/14 at approximately 2:30 PM, electronic supervisory devices were not observed on sprinkler control valves in-line of a sprinkler pipe located in General Stores in the basement.

During the tour of the 5th Floor of the Mental Health building on 09/04/14 at approximately 10:00 AM, it was observed that electronic supervisory devices were not present on sprinkler control valves in-line of a sprinkler pipe located in the room 5M2

During the tour of the 8th floor on 09/02/14 at approximately 12:00 noon, it was noted that the electronic supervisory device was not provided on the standpipe control valve located in the landing of stairway I.


In an interview on 09/11/14 , employee #3 acknowledged the above findings.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 9.7.2.1, 19.3.5.1

069 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 ANSUL system (the range hood fire extinguishing system) in the kitchen were conducted.

Findings:

On 08/28/14, at approximately 2:30 PM, the last documented ANSUL inspection was completed in May 2014 as noted by tags on the pull station and canisters in the 1st Floor Kitchen. There were no documented monthly ANSUL inspections noted prior to and since the service date.

In an interview on 08/28/14 at approximately 2:30 PM, employee #3, stated that a monthly visual inspection was not being done as they were not aware of the requirement.

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
.

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 in the distribution panels located in the basement, kitchen, 8th, 9th, 10th, 11th and 17th Floors.

Findings:

Examples include, but are not limited to the following:

a) On 08/28/14 at approximately 12:00 PM, review of the Emergency Power Panel Directory for Panel "EM1 G A" revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g. Exit Lights) and Emergency System-Critical Branch Loads (e.g., Receptacles for computer).

b) On 08/28/14 at approximately 9:28 AM, review of the Emergency Power Panel Directory for Panel "EMLP-1G-1" in the Emergency Room on the 1st Floor revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., "Peds ER Light" ), Emergency System-Critical Branch Loads (e.g., receptacles) and Emergency System-Equipment Branch Loads (e.g. "copy machine/nurse sta", "refrigerator under panel", "Laser", etc.)

c) On 08/28/14 at approximately 2:00 PM, review of the Emergency Power Panel Directory for Panel "B3EM" in the basement 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 in kitchen office, receptacles in laundry, etc.).

d) On 08/28/14 at approximately 2:30 PM, review of the Emergency Power Panel Directory for Panel "EMPCC" in the Basement East Electrical Room revealed that this Panel served Emergency System-Life Safety Branch Loads (e.g.,Gas Alarm) Emergency System-Critical Branch Loads (e.g., receptacles in Labor and Delivery), Emergency System-Equipment Branch Loads (e.g. exhaust fans, compressor gas pumps, etc.)

e) On 08/29/14 at approximately 10:30 AM, review of the Emergency Power Panel Directory for Panel "EMLP-11D" in the 11th Floor 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).

f) On 08/29/14 at approximately 12:00 PM, review of the Emergency Power Panel Directory for Panel "EMLP-11A" in the 11th Floor A wing Electrical Room revealed that this Panel served Emergency System-Life Safety Branch Loads (e.g.,Medical Gas Alarms) and Emergency System-Critical Branch Loads (e.g., Receptacles, Nurse call system) and Emergency System- Equipment Branch Loads(e.g. Pre-Op Fan Coil, Laser receptacles).

g) On 08/29/14 at approximately 2:50 PM, review of the Emergency Power Panel Directory for Panel "EMLP-11B" in the B Wing 8th Floor Electrical Room revealed that this Panel served Emergency System-Life Safety Branch Loads (e.g., Medical Gas Alarm) and Emergency System-Critical Branch Loads (e.g., Nurses' Call System) and Emergency System-Equipment Branch Loads (e.g., Fan Coil).

h) On 08/29/14 at approximately 10:00 AM, review of the Emergency Power Panel Directory for Panel "O.R B" in the 10th Floor A wing Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Room Lights) and Emergency System-Critical Branch Loads (e.g., Nurse call).

i) On 09/02/14 at approximately 10:00 AM, review of the Emergency Power Panel Directory for Panel "EMLP" in the 9th Floor Electrical Room revealed that this Panel served Emergency System-Life Safety Branch Loads (e.g., Corridor Lights, Exit Lights), Emergency System-Critical Branch Loads (e.g., Headboard in Patient rooms) and Emergency System- Equipment Branch Loads (e.g., pneumatic tube)

j) On 09/04/14 at approximately 10:30 AM, review of the Emergency Power Panel Directory for Panel "EMLP-8B1" in the 8th Floor Electrical Room revealed that this Panel served both Emergency System-Critical Branch Loads (e.g., Respirator receptacle 8B2) Emergency System-Equipment Branch Loads (e.g., 8B4C Refrigerator, GFCI).

k) On 09/04/14 at approximately 11:30 AM, review of the Emergency Power Panel Directory for Panel "EMLP-8B" on the 8th Floor Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Exit Lights, Nurse Sta Oxygen Alarm) and Emergency System-Critical Branch Loads (e.g., Receptacles, Pneumatic Tube System).

l) On 9/09/14 at approximately 10:18 AM, review of the Emergency Power Panel Directory for Panel "EMLP-3" in Room "3A-EL" on 3rd Floor 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, Dukane Nurse Call Panel).

J)On 9/09/14 at approximately 10:18 AM, review of the Emergency Power Panel Directory for Panel "EMLP-3F" on 3rd Floor 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).


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)

1) Based on observation and interview, the facility failed to ensure that a minimum of six (6) outlets served by the Emergency System were provided at the bed location in the Post Anesthesia Care Unit (PACU) in the Labor and Delivery Suite.

Findings:

On 08/29/14 at approximately 10:00 AM, the bed locations in the PACU were observed as providing no more than two duplex emergency outlets.

In an concurrent interview on 08/29/14, Employee #2 stated that Hospital will add more emergency outlets to each bed.

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 in the outpatient Ophthalmology Clinic.

Findings:

On 09/09/14 at approximately 2:30 PM, it was noted that the facility was using relocatable power taps to connect the monitor for the laser in the Ophthalmology laser room.


During interview on 08/13/14 at approximately 2:45 PM, Employee #2, stated that the facility will provide more electrical outlets in the wall to plug in the equipment.

42 CRC 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 all Emergency Power Panel Directories were provided with Panel Directories. This was noted on the 9th, 8th, 3rd, and Ground Floors.

Findings:

From 08/28/14 through 09/09/14 between 9:00 AM and 4:00 PM, the following missing Emergency Power Panel Directories were noted, including, but not limited to:

a) Kitchen Electrical Room - Panel "EMR-EFA" - 18 out of 42 circuit breakers were not identified.

b) 8th Floor Electrical Room - Panel "EMLP-8B" - 14 out of 36 circuit breakers not identified.

c) 9th Floor - Panel "EMLP-9th floor" - 14 out of 42 circuit breakers not identified.

d) 10th Floor A Wing Electrical Room - Panel "LP-O.R. B" - 14 out of 42 circuit breakers not identified.

e) 3rd Floor Electrical Room - Panel "3EMLP-3F" - 22 out of 42 circuit breakers not identified.

f) 8th Floor Electrical Room -Panel "EMLP-8B" - 14 out of 42 circuit breakers not identified.


In an interview on 09/09/14 at approximately 11:00 PM, Employee #2 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



4) Based on observation and interview, the facility failed to ensure that Ground Fault Circuit Interrupters (GFCIs) were provided for hydrocollators (a device that consists of a thermostatically controlled water bath for placing cloth heating pads - the pads are removed from the bath, are placed in covers and the placed on the patient). This was noted in the Physical Therapy Suite.

Findings:

On 09/09/14 , at approximately 11:30 AM, 3 hydrocollators and 2 Fluidotherapy equipment were noted to be plugged into normal outlets instead of GFCI outlets on the 3rd Floor Physical Therapy Rooms.

In an interview on 09/09/14 at approximately 11:45 AM, employee #3 and #2 stated that they were not aware of the requirement to plug these equipment into GFCI outlets since it is not required by the manufacturer.

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

Life Safety code section 19.3.3.2 requires that interior finishes including moveable walls/partitions be in compliance with Section 10.2.3.Section10.2.3.1 requires that interior finishes be in compliance with NFPA 255, Standard method Test of all surfaces Burning Characteristics of building Materials.

Based on observation, staff interview and documentation review, the facility did not ensure all interior finishes for flame spread rating in rooms or spaces not used as corridor have a flame spread rating of class A or B. Specific reference is made to the fact that the facility failed to ensure that the flame retardancy of the 100% polyester cubicle curtains is maintained after they are repeatedly laundered and /or dry cleaned.

Findings include:

During the tour of the central stores on 08/28/14 at approximately 10:30 AM, the surveyors observed that the laundered cubicle curtains were being stored on racks. It was noted that these cubicle curtains did not have the flame spread rating on them or on the package.

During the review of the manufacturer's Fire Tests report on the flame propagation revealed that the manufacturer certified that the cubicle curtain "passes" testing process "initially". According to the same document, the manufacturer requires that the material be tested and certified for flame propagation "After 3 dry cleanings" and "After 5 launderings @160 F".

Upon interview of employee #15, on 08/28/14, at approximately 11:00 AM, it was revealed that the facility did not track the number of launderings and dry cleanings on each cubicle curtain and did not send the material for testing after being laundered and/or dry cleaned. Therefore the facility failed to ensure the flame spread rating of the cubicle curtains were within NFPA 101 specifications of Class A or Class B.

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 observed in smoke barrier walls in the basement and on the 5th and 8th Floors.

Findings:

On 08/28/14, 09/02/14 and 09/04/14, between 9:00 AM and 3:00 PM, unsealed penetrations around wires and conduits, cut holes, improperly sealed, and unfinished wall assemblies were observed in smoke barrier walls in the basement, 5th floor and 8th Floor.

Examples include, but are not limited to the following:


In the basement electrical closet BA11 multiple penetrations around galvanized pipe and conduit and an approximately three (3) inch diameter penetration.

Penetrations around unsealed conduit in the electrical closet 5B-18

Penetrations around two unsealed telecommunication cable conduits above the smoke barrier wall in room 8B-845

Tour of the soiled utility room on 8th Floor revealed that the wall between the soiled utility and clean utility room was unfinished and there was a gap of an inch identified between the wall and the ceiling.

Interview of Employee #2, revealed that the facility staff were sealing the penetrations with firestopping as and when they were being identified.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7.3, 8.3, 8.2.3

Based on observation and interview, the facility failed to ensure that exit access is so arranged that exits are readily accessible at all times.

Findings:

On 08/28/14 at approximately 10:00 AM, the exit from Emergency room to the Ambulance Bay was blocked by 3 Stretcher beds.

In an interview on 08/28/14 at 10:00 AM, employee #4 stated that a storage space for these extra stretcher beds would be identified.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 7.1, 19.2.1

2000 NFPA 101 Life Safety code 9.6.3.2 require that Occupant Notification shall be provided by audible and visible signals.

American Disability Act requires the provision of visible notification devices in conjunction with audible alarms in occupied areas.

Based on observation and staff interview, the facility failed to comply with Life Safety Code and ADA recommendations. Specific reference is made to the audiology clinic, where patients hard of hearing are diagnosed and treated.

Findings include:

During the tour of the audiology clinic located on 6 south of the main building, on 09/09/14 at approximately 2:30 PM, it was noted that the audiology clinic and audiology testing booth did not have the strobes for visible fire alarm notification in case of a fire emergency.

Interview of employee #2 on 09/09/14 concurrently, it was stated that the facility will contact the fire alarm company to install strobes in the clinic as quickly as possible.

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 various locations throughout the building.

Findings:

On 08/28/14 at approximately 2:30 PM, electronic supervisory devices were not observed on sprinkler control valves in-line of a sprinkler pipe located in General Stores in the basement.

During the tour of the 5th Floor of the Mental Health building on 09/04/14 at approximately 10:00 AM, it was observed that electronic supervisory devices were not present on sprinkler control valves in-line of a sprinkler pipe located in the room 5M2

During the tour of the 8th floor on 09/02/14 at approximately 12:00 noon, it was noted that the electronic supervisory device was not provided on the standpipe control valve located in the landing of stairway I.


In an interview on 09/11/14 , employee #3 acknowledged the above findings.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 9.7.2.1, 19.3.5.1

069 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 ANSUL system (the range hood fire extinguishing system) in the kitchen were conducted.

Findings:

On 08/28/14, at approximately 2:30 PM, the last documented ANSUL inspection was completed in May 2014 as noted by tags on the pull station and canisters in the 1st Floor Kitchen. There were no documented monthly ANSUL inspections noted prior to and since the service date.

In an interview on 08/28/14 at approximately 2:30 PM, employee #3, stated that a monthly visual inspection was not being done as they were not aware of the requirement.

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
.

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 in the distribution panels located in the basement, kitchen, 8th, 9th, 10th, 11th and 17th Floors.

Findings:

Examples include, but are not limited to the following:

a) On 08/28/14 at approximately 12:00 PM, review of the Emergency Power Panel Directory for Panel "EM1 G A" revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g. Exit Lights) and Emergency System-Critical Branch Loads (e.g., Receptacles for computer).

b) On 08/28/14 at approximately 9:28 AM, review of the Emergency Power Panel Directory for Panel "EMLP-1G-1" in the Emergency Room on the 1st Floor revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., "Peds ER Light" ), Emergency System-Critical Branch Loads (e.g., receptacles) and Emergency System-Equipment Branch Loads (e.g. "copy machine/nurse sta", "refrigerator under panel", "Laser", etc.)

c) On 08/28/14 at approximately 2:00 PM, review of the Emergency Power Panel Directory for Panel "B3EM" in the basement 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 in kitchen office, receptacles in laundry, etc.).

d) On 08/28/14 at approximately 2:30 PM, review of the Emergency Power Panel Directory for Panel "EMPCC" in the Basement East Electrical Room revealed that this Panel served Emergency System-Life Safety Branch Loads (e.g.,Gas Alarm) Emergency System-Critical Branch Loads (e.g., receptacles in Labor and Delivery), Emergency System-Equipment Branch Loads (e.g. exhaust fans, compressor gas pumps, etc.)

e) On 08/29/14 at approximately 10:30 AM, review of the Emergency Power Panel Directory for Panel "EMLP-11D" in the 11th Floor 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).

f) On 08/29/14 at approximately 12:00 PM, review of the Emergency Power Panel Directory for Panel "EMLP-11A" in the 11th Floor A wing Electrical Room revealed that this Panel served Emergency System-Life Safety Branch Loads (e.g.,Medical Gas Alarms) and Emergency System-Critical Branch Loads (e.g., Receptacles, Nurse call system) and Emergency System- Equipment Branch Loads(e.g. Pre-Op Fan Coil, Laser receptacles).

g) On 08/29/14 at approximately 2:50 PM, review of the Emergency Power Panel Directory for Panel "EMLP-11B" in the B Wing 8th Floor Electrical Room revealed that this Panel served Emergency System-Life Safety Branch Loads (e.g., Medical Gas Alarm) and Emergency System-Critical Branch Loads (e.g., Nurses' Call System) and Emergency System-Equipment Branch Loads (e.g., Fan Coil).

h) On 08/29/14 at approximately 10:00 AM, review of the Emergency Power Panel Directory for Panel "O.R B" in the 10th Floor A wing Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Room Lights) and Emergency System-Critical Branch Loads (e.g., Nurse call).

i) On 09/02/14 at approximately 10:00 AM, review of the Emergency Power Panel Directory for Panel "EMLP" in the 9th Floor Electrical Room revealed that this Panel served Emergency System-Life Safety Branch Loads (e.g., Corridor Lights, Exit Lights), Emergency System-Critical Branch Loads (e.g., Headboard in Patient rooms) and Emergency System- Equipment Branch Loads (e.g., pneumatic tube)

j) On 09/04/14 at approximately 10:30 AM, review of the Emergency Power Panel Directory for Panel "EMLP-8B1" in the 8th Floor Electrical Room revealed that this Panel served both Emergency System-Critical Branch Loads (e.g., Respirator receptacle 8B2) Emergency System-Equipment Branch Loads (e.g., 8B4C Refrigerator, GFCI).

k) On 09/04/14 at approximately 11:30 AM, review of the Emergency Power Panel Directory for Panel "EMLP-8B" on the 8th Floor Electrical Room revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Exit Lights, Nurse Sta Oxygen Alarm) and Emergency System-Critical Branch Loads (e.g., Receptacles, Pneumatic Tube System).

l) On 9/09/14 at approximately 10:18 AM, review of the Emergency Power Panel Directory for Panel "EMLP-3" in Room "3A-EL" on 3rd Floor 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, Dukane Nurse Call Panel).

J)On 9/09/14 at approximately 10:18 AM, review of the Emergency Power Panel Directory for Panel "EMLP-3F" on 3rd Floor 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).


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)

1) Based on observation and interview, the facility failed to ensure that a minimum of six (6) outlets served by the Emergency System were provided at the bed location in the Post Anesthesia Care Unit (PACU) in the Labor and Delivery Suite.

Findings:

On 08/29/14 at approximately 10:00 AM, the bed locations in the PACU were observed as providing no more than two duplex emergency outlets.

In an concurrent interview on 08/29/14, Employee #2 stated that Hospital will add more emergency outlets to each bed.

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 in the outpatient Ophthalmology Clinic.

Findings:

On 09/09/14 at approximately 2:30 PM, it was noted that the facility was using relocatable power taps to connect the monitor for the laser in the Ophthalmology laser room.


During interview on 08/13/14 at approximately 2:45 PM, Employee #2, stated that the facility will provide more electrical outlets in the wall to plug in the equipment.

42 CRC 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 all Emergency Power Panel Directories were provided with Panel Directories. This was noted on the 9th, 8th, 3rd, and Ground Floors.

Findings:

From 08/28/14 through 09/09/14 between 9:00 AM and 4:00 PM, the following missing Emergency Power Panel Directories were noted, including, but not limited to:

a) Kitchen Electrical Room - Panel "EMR-EFA" - 18 out of 42 circuit breakers were not identified.

b) 8th Floor Electrical Room - Panel "EMLP-8B" - 14 out of 36 circuit breakers not identified.

c) 9th Floor - Panel "EMLP-9th floor" - 14 out of 42 circuit breakers not identified.

d) 10th Floor A Wing Electrical Room - Panel "LP-O.R. B" - 14 out of 42 circuit breakers not identified.

e) 3rd Floor Electrical Room - Panel "3EMLP-3F" - 22 out of 42 circuit breakers not identified.

f) 8th Floor Electrical Room -Panel "EMLP-8B" - 14 out of 42 circuit breakers not identified.


In an interview on 09/09/14 at approximately 11:00 PM, Employee #2 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



4) Based on observation and interview, the facility failed to ensure that Ground Fault Circuit Interrupters (GFCIs) were provided for hydrocollators (a device that consists of a thermostatically controlled water bath for placing cloth heating pads - the pads are removed from the bath, are placed in covers and the placed on the patient). This was noted in the Physical Therapy Suite.

Findings:

On 09/09/14 , at approximately 11:30 AM, 3 hydrocollators and 2 Fluidotherapy equipment were noted to be plugged into normal outlets instead of GFCI outlets on the 3rd Floor Physical Therapy Rooms.

In an interview on 09/09/14 at approximately 11:45 AM, employee #3 and #2 stated that they were not aware of the requirement to plug these equipment into GFCI outlets since it is not required by the manufacturer.

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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