HospitalInspections.org

A) (New 03/20/13) Based on random observation on 03/19/13, the surveyor finds that areas open to exit access corridors do not comply with exception # 1 of 19.3.6.1.

Findings include:

1) 6th Floor of Olin Sang: The west seating area in the Elevator Lobby lacks smoke detection in accordance with 19.3.6.1.

2) 6th Floor of Olin Sang?: The Oncology "Wig" area is open to the corridor and lacks smoke detection in accordance with 19.3.6.1.


13755


A. Corrected 03/20/13
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. Deleted 03/20/13
B. Corrected 09/18/12
C. Corrected 09/18/12
D. Corrected 03/20/13E. Corrected 09/18/12
F. Corrected 09/18/12
G. Corrected 03/20/13
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. This item has been corrected with self closing, positive latching, fire rated access panels (03/20/13).

a. Modified 03/20/13: The provider lacks detailed information and plans that identify:

Ducts that penetrate fire rated floor
assemblies

Vertical openings including duct shafts or
open pipe chased that run the more than one
floor

The fire ratings for any and all shafts, vertical
openings and/or chases, including those that
are enclose and not rated but which are
smoke tight enclosures

Information, by floor and by shaft where fire
dampers are installed or not installed.

b. The FSES submitted for this building is not submitted in an acceptable format:

The FSES is not clearly identified in the PoC
by the date that the FSES was prepared and
with the preparer identified.

An FSES is not identified or referenced for
K020

The FSES does not include a scalable set of
plans.

Two hour fire barriers and horizontal exits
are not identified on the FSES Plans

The penalties taken for hazardous areas
in the FSES are not explained.

Based on random observation, the surveyor
finds that is building has unrated shaft
enclosures and it clearly has multiple duct
penetrations of shaft enclosures which lack fire
dampers in accordance with NFPA 90A.
This is not addressed in the PoC and/or the
FSES.

The extent of the above condition is not
known

J. Corrected 09/18/12

A) (New 03/20/13) The surveyor observed that A 2nd Floor corridor is identified with an exit sign at an exit stair for the Nurses Residence Building. The 2nd Floor Exit Stair door does not latch in accordance with NFPA 80.

B) (New 03/20/13) The surveyor finds that Exit Stair 9 transfers from the east side of the Building to the south side of the building at the 3rd Floor. The stair then discharges to the outside at the 1st Floor. However, the exit stair enclosure is deficient at the 3rd Floor and is not protected with a continuous two hour fire rated exit enclosure at the 3rd Floor in accordance with 7.1.3.2.1:

1) A water leak as exposed wood frame construction in this stair; this material is not compatible with the designated construction type of the building and is not permitted to be exposed in a stair.

2) The stair is open to the 3rd Floor corridor above the door to the stair.

3) There are several unsealed holes or penetrations which are not sealed for two hour fire rated construction.

4) There are open electrical junction boxes.

End

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. Deleted 03/20/13
2. Deleted 03/20/13.
3. (Modified 3/20/13)
The Sixth Floor of the Olin-Sang,
Frankel, and Kurtzon Buildings are
served by Exit Stairs 4, 5, 6, 7, 8, and 9.
Of these, only Exit Stair 4 and
Exit Stair 9 discharges
exterior to the building in accordance
with 7.7.1. And Exit Stair 9 has
deficiencies; see K033 Bldg 04.

03/20/13:
The PoC for the above item is too vague.
How many of the stairs identified will
comply with 7.7.1 and how many will
comply with 7.7.2. Which stairs will be
modified to comply and how will they be
modified? The term "protected
corridor" does not identify anything that
complies with 7.7.1 or 7.7.2. If Stair # 5
is to be modified to provide a protected
path to the outside, the requirements for
an Exit Passageway need to be used.

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.

03/20/13:
The PoC for the above item is too vague.
How many of the stairs identified will
comply with 7.7.1 and how many will
comply with 7.7.2. Which stairs will be
modified to comply and how will they be
modified? The term "protected
corridor" does not identify anything that
complies with 7.7.1 or 7.7.2. If Stair # 5
is to be modified to provide a protected
path to the outside, the requirements for
an Exit Passageway need to be used.

B. Deleted 03/20/13

.

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. Deleted 03/20/13
2. The Eleventh, Tenth, Ninth, Eighth, and
Seventh Floors of the Frankel and
Kurtzon Buildings are served by Exit
Stairs 6, 7, 8, and 9. Of these, only
Exit Stair 9 discharges directly to the
exterior of the building. Stair 9 has
deficiencies - see K033
3. The Sixth Floor of the Olin-Sang,
Frankel, and Kurtzon Buildings are
served by Exit Stairs 4, 5, 6, 7, 8, and 9.
Of these, only Exit Stair 4 and
Exit Stair 9 discharge directly to the
exterior of the building. Stair 9 has
deficiencies - see K033 Bldg 04
4. Deleted 03/20/13

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 Twelfth Floor (Engineering
Office/Elevator/Mechanical
Penthouses) of the Frankel Building is
served only by Exit Stair 6 and Exit Stair
7, neither which discharges directly to
the exterior of the building in accordance
with 7.7.1.
2. The Eleventh, Tenth, Ninth, Eighth, and
Seventh Floors of the Frankel and
Kurtzon Buildings are served by Exit
Stairs 6, 7, 8, and 9. Of these, only
Stair 9 discharge directly to the exterior of the
building and Stair 9 has deficiencies.
3. Modified 3/20/13)
The Sixth Floor of the Olin-Sang,
Frankel, and Kurtzon Buildings are
served by Exit Stairs 4, 5, 6, 7, 8, and 9.
Of these, only Exit Stair 4 and Exit Stair
9 discharges exterior to the building in
accordance with 7.7.1. And Exit Stair 9
has deficiencies. See K033 - Bldg 03.

FSES is referenced for K034. The FSES, as
submitted, is not acceptable; see comments
under K020.

4. Deleted 03/20/13
B. Deleted 03/20/13

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. (New 03/20/13): 2nd Floor of Crown: There is a pair of doors with magnetic locking devices and exit signs to the east near Room 200. The provider as not able to demonstrate how these doors comply with 7.2.1.6.1.




14290


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. Deleted 03/20/13
2. Deleted 03/20/13

3. Deleted 03/20/13

Modified 03/20/13: The surveyor observed that stair doors and cross corridor doors in the above 4th Floor unit all have magnetic locking devices. Based on random testing the surveyor finds that magnetic locking device prevents these fire doors from latching.

Further, the surveyor observes that continuos sweeps and gaskets have been installed on many of these fire doors. The facility was not able to provide the documentation that demonstrates that the sweeps and gaskets installed are listed for fire doors.

4. (Modified 03/20/13) Pair of cross corridor doors east of Olin-Sang Elevator Lobby. The exit sign in the four hour vestibule directs the exit path to the east. These is no exit sign visible at the nurses station inside the unit and the signs are confusing on a pair of doors marked as an exit path.

5. (New 03/20/13) The surveyor finds that plans identifying exit access corridors and suite for the 4th Floor Obstetrics Unit. The surveyor observed a pair of doors next to Room C4070. These doors have exit signs and magnetic locking devices that do not comply with 7.2.1.6.1.

B. Corrected 03/20/13
.

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. Eighth Floor East Corridor.

2. Corrected 09/18/12

3. Sixth Floor:
a. Bridge between Frankel and
Kurtzon Buildings. The surveyor
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. 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. Fifth Floor, south leg of West Corridor.

2. Fourth Floor, south leg - West Corridor.

3. Third Floor, south leg of West Corridor.

The FSES is referenced in the PoC for Item A and Item B above. It is not submitted for this building in an acceptable format:

The FSES is not clearly identified in the PoC
by the date that the FSES was prepared and
with the preparer identified.

The PoC includes a reference to an FSES
and Attachment ZZ and a date of 12/16/11.
The date is not the date that the FSES was
prepared and this date is not included on
any part of teh FSES document.
Attachment ZZ was not found.

An FSES is not identified or referenced for
K020

The FSES does not include a scalable set of
plans

Based on random observation, the surveyor
finds that is building has open shaft
enclosures where duct shafts are not
enclosed continuously from deck to deck.
(Example: shaft in middle of building)
Also, duct penetrations of shaft enclosures
lack fire dampers in accordance with NFPA 90A.
This is not addressed in the PoC and/or the
FSES and the FSES is not valid.

The extent of the above condition is not
known

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. 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).

03/20/13: The above doors were repaired; however there is a large hole in the wall above the doors above the ceiling. The doors and wall do not show up on any plan as a fire barrier.
.

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.

03/20/13 - the above item was not corrected in accordance with the last submitted PoC. Based on testing on 03/20/13, the surveyor finds that there are fire doors in multiple directions and the fire doors are located at the fire barriers that are part of the fire separations between this central corridor, Crown and Olin Sang:

1) The pair fire doors to the north and to east of the Security Desk both have magnetic locking device and exit signs above the doors. The doors do not comply with 7.2.1..6.1.

2) Two smoke detectors in this area failed to operate. The facility was not able to demonstrate that each pair of doors with magnetic locks release from activation of smoke detection and the fire alarm system on each side of the doors and that the fire doors with hold open devices at the same locations release the doors in accordance with 7.2.1.8, from activation of smoke detection and the fire alarm system on each side of such doors.

.

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.

03/20/13: The PoC for the above item is not acceptable and an FSES, which indicates that shafts enclosures are not fire rated but which are only smoke tight, is not referenced for this deficiency.

The above item was not corrected in accordance with the last submitted PoC.

It is not clear how this item was investigated and documentation was not available on site. Detailed information for each location and how it is to be corrected was not found.

Fire dampers may be installed in ducts only where they leave a shaft enclosure. The PoC to installed fire dampers at floors does not comply with NFPA 90A

.

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.

03/20/13: The above item was not corrected in accordance with the last submitted PoC. On 03/20/13, the surveyor observed that the provider has no graphic plans which clearly identify the exit access corridors and the suites in and anywhere near the 2nd Floor Surgical Department.

Multiple deficiencies were observed

1) The east-west corridor that is beyond the pair of doors north of the nurses station is clearly a required exit access corridor. It was continuously obstructed by beds, equipment and supplies.

2) All corridors all aisles: 8'-0" widths are provided in this Department but they are continuously lined with beds, equipment, supplies, etc. This condition does not comply 19.2.3.3, and/or 19.3.6.1. The surveyor notes that the volume of storage in the corridors or aisles constitutes hazardous areas which are not separated from all other areas in accordance with 19.3.2.1.

3) There is too much stuff in these corridor and/or aisles; the provider lacks adequate means to prevent re-occurrence.

End

.

A) (New 03/19/13): The provider failed to implement adequate interim life safety measures for the deficiencies observed in a 11th Floor Frankle Project (Hematology IDPH Project 9568). The surveyor observed that this portion of the building was "gutted" and that it had multiple life safety code deficiencies:

1) The project was not separated from the rest of the floor as a hazardous area in accordance with 193.2.1. The project was open to the ceilings and the adjacent exit access corridor; a fire and smoke could quickly spread to all portions of the 11th Floor.

2) There were unprotected openings into the ceiling cavity of the floor below and not in compliance with 19.3.1.1. This condition will allow fire and smoke to spread vertically between floors.

3) There was exposed wiring, open electrical junction boxes and temporary electrical wiring, none of which complies with NFPA 70. These conditions could cause a fire.

4) The ceilings have been removed and the sprinkler system was not modified so that sprinkler heads area installed to comply with NFPA 13. This will delay any activation of the sprinkler system and will delay detection of any fire.

5) Any fire detection devices in the area are too low or they area capped and will not function in accordance with NFPA 72.

6) There was at least one unsealed penetration into Exit Stair 6.

7) Palleted supplies were left in the Elevator Foyer.

The above conditions were not detected and abated by on-going interim life safety measures.

The above conditions were not detected and were not abated by ongoing interim life safety measures.


13755


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).

(03/20/13): A long term project is proposed; this project lacks phasing dates. What will be completed first, what are the priorities, what will be completed last? When will the engineer be hired? When will construction documents be submitted to the Department? When will construction start? How will it be completed: by phase, by floor, by zone?

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).

.(03/20/13): A long term project is proposed; this project lacks phasing dates. What will be completed first, what are the priorities, what will be completed last? When will the engineer be hired? When will construction documents be submitted to the Department? When will construction start? How will it be completed: by phase, by floor, by zone?

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).

(03/20/13): A long term project is proposed; this project lacks phasing dates. What will be completed first, what are the priorities, what will be completed last? When will the engineer be hired? When will construction documents be submitted to the Department? When will construction start? How will it be completed: by phase, by floor, by zone?

.

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).

(03/20/13): A long term project is proposed; this project lacks phasing dates. What will be completed first, what are the priorities, what will be completed last? When will the engineer be hired? When will construction documents be submitted to the Department? When will construction start? How will it be completed: by phase, by floor, by zone?

.