HospitalInspections.org

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Based on observation and staff interview the facility's one (1) hour fire-resistance rated corridor walls were not maintained.

Findings include:

On the afternoon of 01/31/14 observation revealed that the following one (1) hour fire-rated corridor walls were not maintained. Specifically:

1. Within the 1st Floor fire-wall located by Stairwell B there was an unsealed wire bundle penetration, and an improperly sealed wall penetration using mixed materials (i.e. square sheet-rock covering over a hole in concrete).

2. Within the two (2) hour fire/smoke barrier wall of Room B-108J there was one (1) unsealed junction box pipe penetration and one (1) unsealed refrigeration line penetration.

All of the above findings were concurrently verified by Staff #16.
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Based on observation and staff interview the facility's twenty (20) minute fire-rated corridor doors were not maintained.

Findings:

1. On 01/28/14 at 11:15AM observation at the entrance of the Pharmacy Suite revealed that the twenty (20) minute fire-rated corridor entrance door did not close on its own as required. Specifically, the door self closure device did not work because the door was damaged (i.e. dented, etc.).

The above finding was concurrently verified by Staff #16.
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Based on observation and staff interview the facility's one (1) hour fire-resistance rated vertical openings between floors were not maintained.

Findings:

On 01/28/14 at 11:37AM observation in the 2nd Floor Linen Chute Room revealed that there was one (1) unsealed hole in the floor.

The above finding was concurrently verified by Staff #16.
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Based on observation and staff interview the facility's exit access was not marked by approved visible exit signage.

Findings:

1. On 01/27/14 at 11:30AM observation in the Kitchen revealed that the required exit egress signage was missing in the vicinity of the Dishwashing Area.

The above finding was concurrently verified by Staff #16.
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Based on observation and staff interview the facility's one (1) hour fire rated construction for hazardous rooms were not maintained.

Findings include:

1. On 01/27/14 at 2:56PM observation in the Reverse Osmosis Machine Room revealed that an outlet box was pulled out of the wall. Therefore, this was an unsealed wall penetration.

2. On 01/28/14 at 10:10AM observation in the Pathology Lab Hazardous Waste Room revealed that there were two (2) unsealed wall penetrations.

3. On 01/31/13 at 12:30PM observation in the Basement Electrical Closet revealed that there was an unsealed junction box pipe wall penetration.

All of the above findings were concurrently verified by Staff #16.
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Based on observation and staff interview the facility's means of egress was not continuously maintained free of obstruction or impediment in case of an emergency.

Findings include:

1. On 01/27/14 at 2:50PM observation in the Dialysis Center revealed that the means of egress from the Dialysis RO Machine Room was partially blocked by several wheelchairs, two (2) chairs, a scale, etc.

2. On 01/28/14 at 2:20PM observation in the Operating Room Suite revealed that the means of egress at the back of the Operating Room Nursing Station was blocked by three (3) computers on wheels and a Orthopedic equipment cart.

All of the above findings were concurrently verified by Staff #16.
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Based on observation and staff interview the medical gas storage was not protected in accordance with NFPA 99 4.3.1.1.2.

Findings:

On 01/27/14 at 12:00PM observation in the MRI Mechanical Room revealed that there was an unsecured H-sized Helium tank (i.e. it was loose on the floor).

The above finding was concurrently verified by Staff #16.
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Based on observation and staff interview the facility's Type 1 EES was not divided into the Critical Branch, Life Safety Branch and the Emergency System in accordance with NFPA 99.3.4.2.2.2.

Findings include:

1. On 01/31/14 observation revealed that Brooklyn Hospital Center's Type 1 EES was not properly divided. The facility could not provide the Emergency Exit Lighting locations. Specifically:

a. Panel LP8-EC, the 8th Floor Life Safety Panel as per Staff #16, had no panel sheet. The following was written on the panel itself - Defib, Nurse Call, Two (2) Exit, and Lights in Roof Chiller Room. The circuit breakers for the Nurse Call, and the Lights in Roof Chiller Room belong on the Critical Branch. The circuit breaker for the Defib belongs on the Equipment Branch. The nomenclature for "Exit" is unclear whether this is an Emergency light or a Task light.

b. The 6th Floor Life Safety Panel 6-W had the following written on the panel sheet - Four (4) Nurses Call, Physiological Monitors 1 (one) through 12 (twelve), Exit, and Med. Gas pnl. The circuit breakers for the Nurse Call belong on the Critical Branch. The Physiological Monitors belong on the Equipment Branch. The nomenclature for "Exit" is unclear wether this is a Life Safety Emergency light or a Critical Task light.

c. The 5th Floor Life Safety Panel had the following written on the panel sheet - PICU Down Light, Spare PICU, Nurses Call Panel, Outlet Under Panel, Two (2) Tel Rooms, and NS Reception. All of the circuit breakers on this panel belong on the Critical Branch.

d. The 4th Floor Life Safety Panel had the following written on the panel sheet - Three (3) REC Core, Medical Gas Panel, Two (2) Exit Lights, COWS Outlets, Nurses Call, Outlet Below Panel, Defibrillator, Telephone REC, and Nurses Call Visual System Nursery. The circuit breakers for the REC Core, the COWS Outlets, the Outlet Under Panel, the Defibrillator, the Telephone REC and the Nurses Call belong on the Critical Branch.

e. The 4th Floor PP4-E Panel, not a Life Safety panel, had two (2) Fire Dampers identified on the panel sheet. These two (2) circuit breakers belong to the Life Safety Branch.

f. The 3rd Floor Life Safety Panel had the following written on the panel sheet - Two (2) Exit Lights, Two (2) Med Gas, Three (3) Nurses Call, and Two (2) Central Stor. The circuit breakers for the Nurses Call and the Central Stor. belong on the Critical Branch.

g. The 2nd Floor Life Safety Panel LP2EC had the following written on the panel sheet - Three (3) Exit Lights, Telephone Receptacles, Nurses Call Cabinets, IMED, Gas Alarm and Code Blue Operator. The circuit breakers for the Telephone Receptacles, the Nurses Call Cabinets and IMED belong on the Critical Branch.

h. The Basement Life Safety Panel had the following written on the panel sheet - Nurses Call, Defib. Rec., Exit Lights, Med Gas, and Siemens Rec. Trauma. The circuit breakers for the Nurses Call, Defib. Rec. and Siemens Rec. Trauma belong on the Critical Branch.

All of the above findings were concurrently verified by Staff #16.
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Based on observation and staff interview the facility's electrical wiring and equipment was not maintained in accordance with NFPA 70.

Findings:

1. On 01/28/14 at 10:15AM observation in the Chemistry Lab revealed that access to an electrical panel was blocked by a paperwork shelf.

The above finding was concurrently verified by Staff #16.

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Based on observation and staff interview the facility's one (1) hour fire-resistance rated corridor walls were not maintained.

Findings include:

On the afternoon of 01/31/14 observation revealed that the following one (1) hour fire-rated corridor walls were not maintained. Specifically:

1. Within the 1st Floor fire-wall located by Stairwell B there was an unsealed wire bundle penetration, and an improperly sealed wall penetration using mixed materials (i.e. square sheet-rock covering over a hole in concrete).

2. Within the two (2) hour fire/smoke barrier wall of Room B-108J there was one (1) unsealed junction box pipe penetration and one (1) unsealed refrigeration line penetration.

All of the above findings were concurrently verified by Staff #16.
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Based on observation and staff interview the facility's twenty (20) minute fire-rated corridor doors were not maintained.

Findings:

1. On 01/28/14 at 11:15AM observation at the entrance of the Pharmacy Suite revealed that the twenty (20) minute fire-rated corridor entrance door did not close on its own as required. Specifically, the door self closure device did not work because the door was damaged (i.e. dented, etc.).

The above finding was concurrently verified by Staff #16.
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Based on observation and staff interview the facility's one (1) hour fire-resistance rated vertical openings between floors were not maintained.

Findings:

On 01/28/14 at 11:37AM observation in the 2nd Floor Linen Chute Room revealed that there was one (1) unsealed hole in the floor.

The above finding was concurrently verified by Staff #16.
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Based on observation and staff interview the facility's exit access was not marked by approved visible exit signage.

Findings:

1. On 01/27/14 at 11:30AM observation in the Kitchen revealed that the required exit egress signage was missing in the vicinity of the Dishwashing Area.

The above finding was concurrently verified by Staff #16.
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Based on observation and staff interview the facility's one (1) hour fire rated construction for hazardous rooms were not maintained.

Findings include:

1. On 01/27/14 at 2:56PM observation in the Reverse Osmosis Machine Room revealed that an outlet box was pulled out of the wall. Therefore, this was an unsealed wall penetration.

2. On 01/28/14 at 10:10AM observation in the Pathology Lab Hazardous Waste Room revealed that there were two (2) unsealed wall penetrations.

3. On 01/31/13 at 12:30PM observation in the Basement Electrical Closet revealed that there was an unsealed junction box pipe wall penetration.

All of the above findings were concurrently verified by Staff #16.
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Based on observation and staff interview the facility's means of egress was not continuously maintained free of obstruction or impediment in case of an emergency.

Findings include:

1. On 01/27/14 at 2:50PM observation in the Dialysis Center revealed that the means of egress from the Dialysis RO Machine Room was partially blocked by several wheelchairs, two (2) chairs, a scale, etc.

2. On 01/28/14 at 2:20PM observation in the Operating Room Suite revealed that the means of egress at the back of the Operating Room Nursing Station was blocked by three (3) computers on wheels and a Orthopedic equipment cart.

All of the above findings were concurrently verified by Staff #16.
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Based on observation and staff interview the medical gas storage was not protected in accordance with NFPA 99 4.3.1.1.2.

Findings:

On 01/27/14 at 12:00PM observation in the MRI Mechanical Room revealed that there was an unsecured H-sized Helium tank (i.e. it was loose on the floor).

The above finding was concurrently verified by Staff #16.
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Based on observation and staff interview the facility's Type 1 EES was not divided into the Critical Branch, Life Safety Branch and the Emergency System in accordance with NFPA 99.3.4.2.2.2.

Findings include:

1. On 01/31/14 observation revealed that Brooklyn Hospital Center's Type 1 EES was not properly divided. The facility could not provide the Emergency Exit Lighting locations. Specifically:

a. Panel LP8-EC, the 8th Floor Life Safety Panel as per Staff #16, had no panel sheet. The following was written on the panel itself - Defib, Nurse Call, Two (2) Exit, and Lights in Roof Chiller Room. The circuit breakers for the Nurse Call, and the Lights in Roof Chiller Room belong on the Critical Branch. The circuit breaker for the Defib belongs on the Equipment Branch. The nomenclature for "Exit" is unclear whether this is an Emergency light or a Task light.

b. The 6th Floor Life Safety Panel 6-W had the following written on the panel sheet - Four (4) Nurses Call, Physiological Monitors 1 (one) through 12 (twelve), Exit, and Med. Gas pnl. The circuit breakers for the Nurse Call belong on the Critical Branch. The Physiological Monitors belong on the Equipment Branch. The nomenclature for "Exit" is unclear wether this is a Life Safety Emergency light or a Critical Task light.

c. The 5th Floor Life Safety Panel had the following written on the panel sheet - PICU Down Light, Spare PICU, Nurses Call Panel, Outlet Under Panel, Two (2) Tel Rooms, and NS Reception. All of the circuit breakers on this panel belong on the Critical Branch.

d. The 4th Floor Life Safety Panel had the following written on the panel sheet - Three (3) REC Core, Medical Gas Panel, Two (2) Exit Lights, COWS Outlets, Nurses Call, Outlet Below Panel, Defibrillator, Telephone REC, and Nurses Call Visual System Nursery. The circuit breakers for the REC Core, the COWS Outlets, the Outlet Under Panel, the Defibrillator, the Telephone REC and the Nurses Call belong on the Critical Branch.

e. The 4th Floor PP4-E Panel, not a Life Safety panel, had two (2) Fire Dampers identified on the panel sheet. These two (2) circuit breakers belong to the Life Safety Branch.

f. The 3rd Floor Life Safety Panel had the following written on the panel sheet - Two (2) Exit Lights, Two (2) Med Gas, Three (3) Nurses Call, and Two (2) Central Stor. The circuit breakers for the Nurses Call and the Central Stor. belong on the Critical Branch.

g. The 2nd Floor Life Safety Panel LP2EC had the following written on the panel sheet - Three (3) Exit Lights, Telephone Receptacles, Nurses Call Cabinets, IMED, Gas Alarm and Code Blue Operator. The circuit breakers for the Telephone Receptacles, the Nurses Call Cabinets and IMED belong on the Critical Branch.

h. The Basement Life Safety Panel had the following written on the panel sheet - Nurses Call, Defib. Rec., Exit Lights, Med Gas, and Siemens Rec. Trauma. The circuit breakers for the Nurses Call, Defib. Rec. and Siemens Rec. Trauma belong on the Critical Branch.

All of the above findings were concurrently verified by Staff #16.
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Based on observation and staff interview the facility's electrical wiring and equipment was not maintained in accordance with NFPA 70.

Findings:

1. On 01/28/14 at 10:15AM observation in the Chemistry Lab revealed that access to an electrical panel was blocked by a paperwork shelf.

The above finding was concurrently verified by Staff #16.