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Based on observation and staff interview, it was determined that not all of the doors at Richmond University Medical Center (A) have a fire resistance rating of at least one hour; (B) are arranged to provide a continuous path of escape; and (C) provide protection against fire or smoke from other parts of the building. 8.2.5.2, 19.3.1.1

Findings were:

Several fire rated doors (about 59 doors) in different locations were identified by the facility to have deficiencies and lacked the required fire rating as per the provisions of NFPA 101 codes. Examples included, but were not limited to, the following:
1- The 90 minutes fire rated door at PH Stairwell B, identified by the hospital as door #5134, was damaged and had loose light kits and required replacement.
2- The 90 minutes fire rated door at PH Stairwell E, identified by the hospital as door #5135, was damaged, had unused fastener holes in the frame, was missing its top flush bolt and had incorrect clearance (top of the door frame).
3- The 90 minutes fire rated door at the 6th floor Soiled Laundry, identified by the hospital as door #5141, was damaged and had incorrect hinges and incorrect clearance (lock edge to frame).
4- The 45 minutes smoke door on the 5th floor, identified by the hospital as door #5146, was damaged, and the door bottom drags against floor.
5- The 90 minutes fire rated door near the 5th floor electric closet, identified by the hospital as door #5161, was damaged, missing its label, did not have a positive latch and was missing latch bolt assembly (bottom).

The hospital's Director of Facilities and Vice President of Operation acknowledged the identified door deficiencies and have a plan to correct those deficiencies. As per the hospital staff, the plan for correcting the door problems will take a long time to complete, and the hospital may request a time limited waiver in order to maintain their compliance.

Based on observation and staff interview, Richmond University Medical Center's means of egress were not continuously maintained free of all obstructions or impediments to their full instant use in the case of fire or other emergency.

The findings were:

On the afternoon of 12/2/2014, during a tour of the hospital, the following finding was identified and acknowledged by the Director of Facilities and Vice President of Operation:

The corridors and exit way of the subbasement receiving corridor was observed to be partly blocked by many boxes that were observed being stored and unattended on 12/2/2014 at 1:50 PM.

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 Operating Room #2 and #6.

Findings:

On 12/02/14, between 10:00 AM and 12:00 PM, the following was noted:

(a) Relocatable power taps were noted to be used in connecting the sequential compression machine and surgical field equipment in Operating Room (OR) #6.
(b) Relocatable tab was observed to be installed on an Anesthesia cart and a warmer equipment was observed to be connected to the relocatable tab.




21204

Based on observation and staff interview, the Richmond University Medical Center's Type I Essential Electrical System (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. Electrical System (EES) ,with NFPA 70, Article 700 Emergency Systems and NFPA 110, Standard for Emergency and Standby Power Systems.

The findings were:

On the morning of 12/4/2014 observation and interview with Director of Facilities revealed the following: Many Emergency Electric panels were found to supply a mix of devises that belong to various branches of the EES system, which proves that the Hospital EES system is not in compliance with EES type 1 that is required for hospitals in accordance with NFPA 99. 3.4.2.2.2.

Examples included, but were not limited to:

1- Panel EL2 of the Operating Rooms - on the second floor of Seton Building - this panel had different devices that belong to more than one branch; examples included, but were not limited to:
a- Exit lights, lights of the corridor 2-70, (Life safety Branch)
b- Oxygen Alarm (Life safety Branch)
c- Nitro Alarm (Life safety Branch)
d- Water heater (Equipment Branch)
e- Ground detector (Equipment Branch)
f- Lights of the recovery room center (Critical Branch).

2- Emergency Electric Panels, identified as SLB1 and located in the floor of the maternity /newborn nursing suites.
a- Voice mail - Operation Room (Life Safety Branch)
b- Nurse call panel (Critical Branch).
c- Receptacles in room #1094, #1079, #1050 and #1076 (Critical Branch).

3- Panel LPE2B -Recovery, Medical ICU and Surgical ICU had devices that belong to more than one branch of the EES type 1 system.

4- Panel 3CL-1 located at Pediatric and NICU had devices that belong to more than one branch of the EES type 1 system.

5- Emergency Electric panel for Operating Room on the second floor of Spellman Building had devices that belong to more than one branch of the EES type 1 system.

The above findings were also identified by the facility as deficiencies, and the Vice President of Operation and the Director of Facilities acknowledged that the hospital's EES system does not comply with the EES Type 1 system in accordance with NFPA 99. 3.4.2.2.2. However, the hospital promised to take the necessary steps to correct this deficiency.

Based on observation and staff interview, it was determined that not all of the doors at Richmond University Medical Center (A) have a fire resistance rating of at least one hour; (B) are arranged to provide a continuous path of escape; and (C) provide protection against fire or smoke from other parts of the building. 8.2.5.2, 19.3.1.1

Findings were:

Several fire rated doors (about 59 doors) in different locations were identified by the facility to have deficiencies and lacked the required fire rating as per the provisions of NFPA 101 codes. Examples included, but were not limited to, the following:
1- The 90 minutes fire rated door at PH Stairwell B, identified by the hospital as door #5134, was damaged and had loose light kits and required replacement.
2- The 90 minutes fire rated door at PH Stairwell E, identified by the hospital as door #5135, was damaged, had unused fastener holes in the frame, was missing its top flush bolt and had incorrect clearance (top of the door frame).
3- The 90 minutes fire rated door at the 6th floor Soiled Laundry, identified by the hospital as door #5141, was damaged and had incorrect hinges and incorrect clearance (lock edge to frame).
4- The 45 minutes smoke door on the 5th floor, identified by the hospital as door #5146, was damaged, and the door bottom drags against floor.
5- The 90 minutes fire rated door near the 5th floor electric closet, identified by the hospital as door #5161, was damaged, missing its label, did not have a positive latch and was missing latch bolt assembly (bottom).

The hospital's Director of Facilities and Vice President of Operation acknowledged the identified door deficiencies and have a plan to correct those deficiencies. As per the hospital staff, the plan for correcting the door problems will take a long time to complete, and the hospital may request a time limited waiver in order to maintain their compliance.

Based on observation and staff interview, Richmond University Medical Center's means of egress were not continuously maintained free of all obstructions or impediments to their full instant use in the case of fire or other emergency.

The findings were:

On the afternoon of 12/2/2014, during a tour of the hospital, the following finding was identified and acknowledged by the Director of Facilities and Vice President of Operation:

The corridors and exit way of the subbasement receiving corridor was observed to be partly blocked by many boxes that were observed being stored and unattended on 12/2/2014 at 1:50 PM.

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 Operating Room #2 and #6.

Findings:

On 12/02/14, between 10:00 AM and 12:00 PM, the following was noted:

(a) Relocatable power taps were noted to be used in connecting the sequential compression machine and surgical field equipment in Operating Room (OR) #6.
(b) Relocatable tab was observed to be installed on an Anesthesia cart and a warmer equipment was observed to be connected to the relocatable tab.




21204

Based on observation and staff interview, the Richmond University Medical Center's Type I Essential Electrical System (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. Electrical System (EES) ,with NFPA 70, Article 700 Emergency Systems and NFPA 110, Standard for Emergency and Standby Power Systems.

The findings were:

On the morning of 12/4/2014 observation and interview with Director of Facilities revealed the following: Many Emergency Electric panels were found to supply a mix of devises that belong to various branches of the EES system, which proves that the Hospital EES system is not in compliance with EES type 1 that is required for hospitals in accordance with NFPA 99. 3.4.2.2.2.

Examples included, but were not limited to:

1- Panel EL2 of the Operating Rooms - on the second floor of Seton Building - this panel had different devices that belong to more than one branch; examples included, but were not limited to:
a- Exit lights, lights of the corridor 2-70, (Life safety Branch)
b- Oxygen Alarm (Life safety Branch)
c- Nitro Alarm (Life safety Branch)
d- Water heater (Equipment Branch)
e- Ground detector (Equipment Branch)
f- Lights of the recovery room center (Critical Branch).

2- Emergency Electric Panels, identified as SLB1 and located in the floor of the maternity /newborn nursing suites.
a- Voice mail - Operation Room (Life Safety Branch)
b- Nurse call panel (Critical Branch).
c- Receptacles in room #1094, #1079, #1050 and #1076 (Critical Branch).

3- Panel LPE2B -Recovery, Medical ICU and Surgical ICU had devices that belong to more than one branch of the EES type 1 system.

4- Panel 3CL-1 located at Pediatric and NICU had devices that belong to more than one branch of the EES type 1 system.

5- Emergency Electric panel for Operating Room on the second floor of Spellman Building had devices that belong to more than one branch of the EES type 1 system.

The above findings were also identified by the facility as deficiencies, and the Vice President of Operation and the Director of Facilities acknowledged that the hospital's EES system does not comply with the EES Type 1 system in accordance with NFPA 99. 3.4.2.2.2. However, the hospital promised to take the necessary steps to correct this deficiency.