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Based on observation on the afternoon of 6/6/11 the hospital did not ensure that access to exits was marked by approved, readily visible signs.

Findings:

1. On the 7th floor Tower building medical surgical unit exits signs were obstructed by crash cart signs hanging from the ceiling.

2. Exit sign were not readily visible from all parts of the power plant.

Based on record review and staff interview on the afternoon of 6/1/11 the hospital did not ensure that all staff members are familiar with fire safety procedures.

Findings:

1. No documentation was available to show that surgeons and anesthesiologists are in-serviced in the hazards that could be encountered during sugical procedures. This was confirmed in interview with staff # 2.
NFPA 99 1999 12-4.1.2.10

2. No documentation was available to show that surgeons and anesthesiologists participate in site specific fire drills in the oepating room.
NFPA 99 1999 12-4.1.2.10.

3. The hospital's fire plan does not include an evaluation of the hazards that could be encountered during surgical procedures.
NFPA 99 1999 12-4.1.2.10.

4. Review of fire drill records show no participation by physicians in any fire drill conducted by the hospital.

Based on observation the hospital did not ensure that all means of egress were continuously maintained to provide full instant use in the event of emergency.

Finding:

On the afternoon of 6/3/11 the Stair "C" exit discharge door was sticking requiring greater than 15 lbf to open. A very heavy accumulation of debris was noted on the floor on the egress side of the door. Approximately 50-60 cigarette butts were noted on the ground just outside the door indicating evidence of smoking.

Based on document review and interview the maintenance of the hospital's elevators do not conform to the requirements of ASME / ANSI A17.3 and Local Law # 10/81.

Findings:

1. Elevator maintenance records for Category 1 and Category V inspections were requested from employee # 8 on 6/2/, 6/3 and 6/6/2011 but were not provided during the survey. In interview employee # 8 stated that the inspection reports were sent into the NYC Department of Buildings and that he has been trying to get a copy from them.

2. Credentials of the technician performing the elevator inspections were requested but not provided.

3. No documentation was available to show that the elevators are being maintained in accordance with the hospital's contract with the vendor. The hospitals contract calls for weekly, semimonthly, monthly, quarterly, semi-annual, and annual inspections (including Local Law #10/81). Only documentation of daily inspections was provided during survey.

Based on observation on the afternoon of 6/6/11 the hospital did not ensure that access to exits was marked by approved, readily visible signs.

Findings:

1. On the 7th floor Tower building medical surgical unit exits signs were obstructed by crash cart signs hanging from the ceiling.

2. Exit sign were not readily visible from all parts of the power plant.

Based on record review and staff interview on the afternoon of 6/1/11 the hospital did not ensure that all staff members are familiar with fire safety procedures.

Findings:

1. No documentation was available to show that surgeons and anesthesiologists are in-serviced in the hazards that could be encountered during sugical procedures. This was confirmed in interview with staff # 2.
NFPA 99 1999 12-4.1.2.10

2. No documentation was available to show that surgeons and anesthesiologists participate in site specific fire drills in the oepating room.
NFPA 99 1999 12-4.1.2.10.

3. The hospital's fire plan does not include an evaluation of the hazards that could be encountered during surgical procedures.
NFPA 99 1999 12-4.1.2.10.

4. Review of fire drill records show no participation by physicians in any fire drill conducted by the hospital.

Based on observation the hospital did not ensure that all means of egress were continuously maintained to provide full instant use in the event of emergency.

Finding:

On the afternoon of 6/3/11 the Stair "C" exit discharge door was sticking requiring greater than 15 lbf to open. A very heavy accumulation of debris was noted on the floor on the egress side of the door. Approximately 50-60 cigarette butts were noted on the ground just outside the door indicating evidence of smoking.

Based on document review and interview the maintenance of the hospital's elevators do not conform to the requirements of ASME / ANSI A17.3 and Local Law # 10/81.

Findings:

1. Elevator maintenance records for Category 1 and Category V inspections were requested from employee # 8 on 6/2/, 6/3 and 6/6/2011 but were not provided during the survey. In interview employee # 8 stated that the inspection reports were sent into the NYC Department of Buildings and that he has been trying to get a copy from them.

2. Credentials of the technician performing the elevator inspections were requested but not provided.

3. No documentation was available to show that the elevators are being maintained in accordance with the hospital's contract with the vendor. The hospitals contract calls for weekly, semimonthly, monthly, quarterly, semi-annual, and annual inspections (including Local Law #10/81). Only documentation of daily inspections was provided during survey.