HospitalInspections.org

Based on random observation during the survey walk-through, not all exit access corridors are separated from use areas in accordance with 19.3.6.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of smoke detectors could result delayed response to fire/smoke conditions which compromise the facility's use of the exit access corridors.

Findings include:

A. The Basement Waiting area near Nuclear Med is open to the corridor. Only a single smoke detector is provided and not located near the actual seating area. Adequate coverage of the waiting space is not deemed to be met to comply with 19.3.6.1 Exception No. 2.

B. Corrected 09/18/12
C. Corrected 09/18/12
D. Corrected 09/18/12

Based on random observation during the survey walk-through on the afternoon of September 26, 2011, vertical openings between floors are not protected to comply with 19.3.1.1. These deficiencies could affect all patients in the facility, as well as any staff and visitors present, because the lack of protection can allow smoke and fire to migrate from one floor to another.

Findings include:

A. The 13th floor Equipment room was observed with three ducts through the floor. Fire dampers were not observed to be installed. Although this equipment was indicated to be abandoned in-place and not operating, it was not able to be confirmed what areas were served by the equipment relative to the ducts penetrating more than one floor.

B. Corrected 09/18/12
C. Corrected 09/18/12
D. The 12the floor office below the Elevator Penthouse was observed to have a non-fire resistance rated steel floor plate assembly at the equipment hoisting penetration.

E. Corrected 09/18/12
F. Corrected 09/18/12


G. Electric Vault #2 at the Basement level was observed to have an opening in the base of the wall which appeared to be the bottom of a shaft in which air movement was into the shaft. A sheetmetal cover was not installed and did not maintain the required fire rating of the shaft wall.

H. Corrected 09/18/12


I. The Frankel building contains multiple access doors along the corridor walls which access chases (where only piping or conduit is sealed at the floor levels) or shafts (where the ducts extend through the floors). A clear delineation between those functioning as shafts from those functioning as chases was not apparent. The original installed access doors contained "Fire Door" labels without an hourly rating identified.

J. Corrected 09/18/12

Based on random observation during the survey walk-through, not all stair shafts used as exits are constructed in accordance with 7.2. These deficiencies could affect all occupants of the building because their ability to exit the building and reach a public way could be compromised.

Findings include:

A. During document review and staff interview conducted in the Facilities Office at 11:15 AM on September 27, 2011, it was determined that several building stories do not comply with 7.7.2. because less than 50 per cent of the exit stairs serving those building stories discharge directly to the exterior of the building. During the interview listed above, the provider's Vice President for Facilities confirmed the following:
1. The Thirteenth/Twelfth Floors (Elevator/Mechanical Penthouses ) of the Frankel Building are served only by Exit Stair 6, which does not exit directly to the exterior of the building.
2. The Eleventh, Tenth, Ninth, Eighth, and Seventh Floors of the Frankel and Kurtzon Buildings are served by Exit Stairs 6, 7, 8, and 12. Of these, none discharge directly to the exterior of the building.
3. The Sixth Floor of the Olin-Sang, Frankel, and Kurtzon Buildings are served by Exit Stairs 4, 5, 6, 7, 8, and 12. Of these, only Exit Stair 4 discharges exterior to the building.

4. The Sub-Basement of the Olin-Sang Building is served by Exit Stairs 5 and 13. Of these, none discharge directly to the exterior of the building.
B. Corrected 09/18/12

Based on random observation during the survey walk-through, not all stair shafts used as exits are constructed in accordance with 7.2. These deficiencies could affect all occupants of the building because their ability to exit the building and reach a public way could be compromised.

Findings include:

A. During document review and staff interview conducted in the Facilities Office at 11:15 AM on September 27, 2011, it was determined that several building stories do not comply with 7.7.2. because less than 50 per cent of the exit stairs serving those building stories discharge directly to the exterior of the building. During the interview listed above, the provider's Vice President for Facilities confirmed the following:
1. The Thirteenth/Twelfth Floors (Elevator/Mechanical Penthouses ) of the Frankel Building are served only by Exit Stair 6, which does not exit directly to the exterior of the building.
2. The Eleventh, Tenth, Ninth, Eighth, and Seventh Floors of the Frankel and Kurtzon Buildings are served by Exit Stairs 6, 7, 8, and 12. Of these, none discharge directly to the exterior of the building.
3. The Sixth Floor of the Olin-Sang, Frankel, and Kurtzon Buildings are served by Exit Stairs 4, 5, 6, 7, 8, and 12. Of these, only Exit Stair 4 discharges exterior to the building.

4. The Sub-Basement of the Olin-Sang Building is served by Exit Stairs 5 and 13. Of these, none discharge directly to the exterior of the building.
B. During document review and staff interview conducted in the Facilities Office at 11:15 AM on September 27, 2011, it was determined that building occupants must exit the fire rated enclosure for Exit Stair 12 at the Third Floor of the Kurtzon Building and cross through the building in a non-fire rated corridor in order to gain access to the fire rated enclosure for Exit Stair 9 to continue egress, which does not comply with 7.2.6.3.

.

Based on random observation during the survey walk-through on the afternoon of September 26 and on September 27, 2011, not all exit access is arranged so that exits are readily accessible at all times in accordance with 19.2.1 and Chapter 7. These deficiencies could affect all patients expected to utilize the exit access and/or exit, as well as any staff and visitors present, by preventing those occupants from reaching an exit and/or the exterior of the building.

Findings include:

A. Doors were observed to be provided with dead bolt locks in addition to lock/latchsets. Where the dead bolt locks are operable from the egress side, the dead bolt lock constitutes a second releasing operation to operate the door when used in combination with a latchset in noncompliance with 7.2.1.5.4. Locations observed include but are not necessarily limited to the following:

1. Corrected 09/18/12
2. Corrected 09/18/12

3. The 3rd floor room F330 is equipped with both a dead bolt lock and a latchset.

B. The Basement level of the west stair contains an electrical panel in non-compliance with 7.1.3.2.1(e).

.

Based on random observation during the survey walk-through and staff interview, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1.

Findings include:

A. Doors equipped with delayed egress functions were observed to lack identifying signage required by 7.2.1.6.1(d). During an interview held in a Fourth Floor Conference Room at 11:57 AM on September 27, 2011, the Nurse Manager for the Mother/Baby Unit confirmed this observation. These deficiencies could affect all occupants of the Fourth Floor of the Crown Building because they may become confused when the doors do not release to permit egress under emergency conditions. Locations observed include (all Fourth Floor Mother/Baby Unit):
1. Exit Stair 1.
2. Exit Stair 2.

3. Exit Stair 3.

4. Pair of cross-corridor doors east of Olin-Sang Elevator Lobby.

B. The floor levels at 4 exterior exit doors, all in the immediate area of the First Floor exit discharge for exit Stair 3, were observed to not be level, as required by 7.1.7.2., because there is a step immediately outside each of the 4 doors. This deficiency could affect all building occupants exiting the building at this point, as the condition forms a tripping hazard which may prevent safe egress away from the building.
.

Based on random observation during the survey walk-through, not all exit accesses are arranged so that exits are readily accessible at all times in accordance with 19.2.1. These deficiencies could affect all occupants of the listed building stories of the Kurtzon Building because their ability to successfully exit the building under fire conditions could be compromised.

Findings include:

A. Dead-end corridors of excessive length (in fire compartments classified as existing health care occupancies) were observed as prohibited by 19.2.5.10. Locations observed include:

1. 1:48 PM September 26, 2011: Eighth Floor East Corridor.

2. Corrected 09/18/12

3. Sixth Floor:
a. 2:17 PM September 26, 2011: Bridge between Frankel and Kurtzon Buildings. Surveyor 14290 notes that the dead-end corridor exists because the door to the Kurtzon Building at the south end of the Bridge is secured against passage to the south.
b. 2:18 PM September 26, 2011: East Corridor.
B. Dead-end corridors in excess of 50'-0" in length (in fire compartments classified as existing business occupancies) were observed as prohibited by 39.2.5.2. Locations observed include:

1. 2:45 PM September 26, 2011: Fifth Floor, south leg of West Corridor.

2. 2:53 PM September 26, 2011: Fourth Floor, south leg of West Corridor.

3. 9:20 AM September 27, 2011: Third Floor, south leg of West Corridor.

C. Corrected 09/18/12

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies.

Findings include:

A. 1:59 PM September 27, 2011: The north leaf of a pair of cross-corridor doors, located in the west 2 hour fire rated wall at a "Chicago Vestibule" immediately east of First Floor Sinai Central, was observed to not release to close under fire alarm conditions as required by 7.2.4.3.4. and 8.2.3.2.3.1(1). This deficiency could affect all occupants of the First Floor of the Crown and Olin-Sang Buildings because the unreleased door could permit fire and smoke to pass between fire compartments.

.

Based on random observation during the survey walk-through, not all designated or required horizontal exits or fire barriers are constructed or maintained as fire resistive assemblies.

Findings include:

A. 9:46 AM September 27, 2011: A pair of cross-corridor doors, located in a designated 2 hour fire barrier wall immediately west of the Second Floor landing for Exit Stair 8, were observed to be damaged to a point at which they no longer carry a minimum 1-1/2 hour fire resistance rating as required by 7.2.4.3.4. and 8.2.3.2.3.1(1). This deficiency could affect all occupants of the Kurtzon Building Second Floor because the damaged doors could permit fire and smoke to pass between fire compartments.

.

Based on random observation during the survey walk-through on September 27, 2011, exit signs did not identify available paths of egress in all cases in accordance with 19.2.5.9, 19.2.10.1. and 7.10. These deficiencies could affect all patients in the smoke compartment, as well as any staff and visitors present, by preventing those occupants from reaching an exit from the smoke compartment or building.

Findings include:

A. Corrected 09/18/12
B. Corrected 09/18/12
C. Corrected 09/18/12
D. Corrected 09/18/12
E. Corrected 09/18/12
F. Corrected 09/18/12

G. The door at the south end of the 2nd floor west corridor is not marked as an exit path from the unit to the elevator lobby and constitutes a dead end of 38'+/-. It appears to be equipped with only a portion of the features required by 7.2.1.6.2 as an access controlled egress locking device to control movement into the unit. Egress from the last patient room adjacent the door does not activate the door lock release. A manual release is not provided.

H. The door at the south end of the 3rd floor west corridor is not marked as an exit path from the unit to the elevator lobby and constitutes a dead end of 38'+/-. The door is locked with a magnetic locking device without delayed egress or access controlled egress hardware. Staff indicated that the door only releases under fire alarm activation. Adequate signage is not otherwise provided to define the available exit paths or make it clear that this door is not part of the required means of egress.

1. This similar condition also exist on the 4th floor south end of the west corridor.

2. This similar condition also exist on the 5th floor south end of the west corridor.

3. This similar condition also exist on the 6th floor south end of the west corridor.
I. Corrected 09/18/12
J. Corrected 09/18/12
K. Corrected 09/18/12

.

Based on random observation during the survey walk-through on September 27, 2011, not all portions of the facility's fire alarm system are installed in accordance with NFPA 72 1999.

Findings include:

A. During the walk-through of the basement the intersection between the Crown and Olin Sang Buildings was observed with a smoke detector installed within 3' of a supply diffuser and not in accordance with 2-3.5.1.

This deficiency could cause injury to patients and staff due to delay of sensing smoke.

.

Based on random observation during the survey walk-through, not all stair or ventilation shafts are constructed or maintained as fire resistive assemblies in accordance with 19.3.1.1.

Findings include:

A. September 26, 2011, varying times throughout the afternoon, and September 27, 2011, varying times throughout the morning: The conditions listed below were observed at a centrally located shaft within the Kurtzon Building (example location: at the Ninth Floor immediately southeast of the intersection between the East-West Corridor and the South Corridor). The shaft connects at least the Eleventh through Fourth Floors. These deficiencies could affect any occupants of the Kurtzon Building because fire and smoke could pass between building stories. Conditions observed include:

1. No evidence of fire dampers, required by 8.2.3.2.4.1. and NFPA 90A 1999 3-3.4.4. was found on any building story in which ductwork was observed in the shaft.
2. No access panels for any fire dampers, required by NFPA 90A 1999 2-3.4.1., were found on any building story in which ductwork was observed in the shaft.
3. The shaft, which connects at least 8 building stories, was observed to not carry a minimum 2 hour fire rating as required by NFPA 90A 1999 3-3.4.1., because multiple unsealed penetrations and openings (see 8.2.2. and 8.2.3.2.4.2.) were observed in the shaft on all building stories observed.

.

Based on random observation during the survey walk-through, not all portions of the facility's heating and air conditioning system are in accordance with NFPA 90A 1999.

Findings include:

A. During the survey of the sixth floor equipment room AHU #1 was observed to have heavily soiled and loose fitting pre-filters allowing air bypass. Staff interview at the site reveled the filters had not been changed in six months.

.

Based on random observation during the survey walk-through and staff interview, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3.

Findings include:

A. 2:25 PM September 27, 2011: A gurney was observed, in the Second Floor Surgical Department East-West Corridor, that obstructs egress as prohibited by 19.2.3.3. and 7.1.10.2.1. During an interview held at that time, the provider's Surgical Nurse manager stated that gurneys are typically placed in that Corridor while patients undergo procedures. This deficiency could affect all occupants within the Surgical Department because their ability to reach an exit from the building story could be compromised under emergency conditions.

.

Based on random observation during the survey walk-through, not all portions of the facility's piped medical gas system are installed and maintained in accordance with NFPA 99 1999.

Findings include:

A. During the walk-through of the facility grounds the Emergency Oxygen fill location was observed to be without a sign identifying it as the "Emergency Low Pressure Gaseous Oxygen Inlet" in accordance with 4-3.1.1.8 (h).

B. The medical air 1 and 2 receiver was observed without a source valve at the receiver in accordance with 4-3.1.2.3 (a).

C. The medical air 1 and 2 receiver was observed without an automatic drain in accordance with 4-3.1.1.9 (f).

These deficiencies could result in patient injury due to system failure.

.

Based on random observation during the survey walk-through, not all portions of the facility's piped medical gas system are installed in accordance with NFPA 99 1999.

Findings include:

A. During the walk-through of the basement level electrical switchgear room OS39 had 3 copper lines crossing the ceiling identified as medical gas lines. During an interview held with the Operation Manager at the location it was revieled they might be abandoned but it was not confirmed at the time of the survey.

This deficiency could injury patients or staff due to increased fire hazard.

.

A. Corrected 09/18/12



14290


Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

B. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.


Findings include:

1. Emergency loads were not separated into life safety, critical and equipment branches which does not meet the requirements of NFPA-70, Section 517-31 thru 35.

2. Transfer switches served locations rather than specific branches of the emergency system which does not meet the requirements of NFPA-70, Section 517-30(b)(4).

.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.


Findings include:

1. Emergency panels throughout the building were serving both life safety and critical loads which does not meet the requirements of NFPA-70, Section 517-31 thru 35.

2. Transfer switches served locations rather than specific branches of the emergency system which does not meet the requirements of NFPA-70, Section 517-30(b)(4).

.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.


Findings include:

1. The critical rather than life safety panels on each floor were serving med gas alarms, exit signs, and emergency lighting which does not meet the requirements of NFPA-70, Section 517-31 thru 35.

2. Transfer switches served locations rather than specific branches of the emergency system which does not meet the requirements of NFPA-70, Section 517-30(b)(4).

.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised.


Findings include:

1. The critical rather than life safety panels on each floor were serving med gas alarms, exit signs, and emergency lighting which does not meet the requirements of NFPA-70, Section 517-31 thru 35. Examples include panel 5CR1 and 4CR2 which were serving med gas alarms and corridor emergency lighting.

2. Transfer switches served locations rather than specific branches of the emergency system which does not meet the requirements of NFPA-70, Section 517-30(b)(4).

.

Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

1. Normal power receptacles were not provided in C-section rooms as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, the operating rooms could be left with no power.

.