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) Corrected 01/22/14

2) Corrected 01/22/14

3) (New 1/22/14): The 2nd Floor Main Elevator Lobby had a bench, several chairs and a table on one side of the exit access corridor in this area. This area lacked smoke detection in order to comply 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

A) (New 01/22/14): The corridor door to Room 200B was wedged open with two wedeges.

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.

J. Corrected 09/18/12

A) (New 01/22/14The 11th Floor new Lab Project has a designated one hour corridor wall with multiple holes and penetaations above the ceiling which have not be sealed in accordance with 18.3.2.1.

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) Corrected 01/22/14

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. (Modified 01/22/14During 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 in accordance
with 7.7.1.

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 9
discharge directly to the
exterior of the building.

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. Deleted 03/20/13
2. Deleted 03/20/13.
3. (Modified 01/22/14)
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, Exit Stair 9 discharges
exterior to the building in accordance
with 7.7.1.

Although identified as such, On
01/22/14, the provider was not
able to demonstrate how Stair # 4
complies with 7.7.1.

The vestibule between this exit stair and
the outside is not identified on any plans
as an exit passageway. The walls for
this vestibule are not identified on any
plans as two hour fire barriers. 1 1/2
hour fire doors in this vestibule are not
documented anywhere. One of the
doors in this vestibule serves a
hazardous area. The provider has not
adopted the categorical waiver for this
condition.

There was a medicine cart in the
vestibule which has been cited in the
past; the provider lacks effective means
to prevent re-occurrence.

The vestibule was being used to store
xmas decorations. The provider lacks
adequate means to find and abate such
conditions.

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. 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. 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.

01/22/14: The PoC does not indicate
when teh corrections for Stair 6 will
be submitted to IDPH as a project for
review and approval. The POC for
Stair 6 for Item A 2 does not match
teh PoC for Stair 6 under Item A 3.
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.
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
9 discharges exterior to the building in
accordance with 7.7.1.

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.

B. (New 01/22/14): A wheelchair was left in the 2nd Floor Chicago Vestibule east of the surgical unit. The vestibule is part of a building separation and is part of the means of egress. The wheelchair obstructed the exit path and the door swing.


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 do not comply with 7.2.1.6.1(d):
1. Deleted 03/20/13
2. Deleted 03/20/13

3. Deleted 03/20/13

4. Corrected 01/22/14

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.

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.

1) Corrected 01/22/14

2) The facility was not able to demonstrate that each pair of 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.

01/22/14: The pair of fire doors south and west of the security desk in Sinai Central failed to close from activation of the smoke detector directly east of the doors. The pair of fire doors within the same fire/smoke compartment to the north also failed to close from this smoke detector. (Theses doors do not comply with 19.2.2.2.6).

A. (New 01/22/14: 6th Floor Kurtzon Psychiatric Unit: The exit stair in the east corridor has a STAIR sign but lacks an EXIT sign in accordance with 19.2.10.1.

A) (New 01/22/14): Based on random observation, the surveyor finds that sprinkler systems are not installed and maintained in accordance with NFPA 13.

Findings include:

1) 2nd Floor of Crown - the missing ceiling tile in the corridor near Room A221 compromises sprinkler protection in this area.

2) The surveyor observed an IT Closet in a 2nd Floor corridor (opposite the wall with the time card racks). This closet lacked sprinkler protection and does not otherwise comply with NFPA 13 as an unsprinklered space (not enclosed in two hour construction).

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 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.

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 still lacks adequate means to prevent re-occurrence.

End

.

A) Corrected 01/22/14




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).

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).

A) (New 01/22/14): The corridor door to Room 200B was wedged open with two wedeges.