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Based on observation and staff interview, the facility failed to ensure that a readily visible, durable emergency sign, in accordance with NFPA 101 2012 Edition, was posted on the egress side of each door opening of a power sliding door located in the means of egress.

Findings include:

On 12/12/2017 at approximately 12:00 PM, it was observed that the main hospital entrance power sliding door did not have the required readily visible, durable sign in letters of not less than 1 inch (25 mm) high on a contracting background that reads: "IN EMERGENCY, PUSH TO OPEN " on the egress side of each sliding door, in accordance with NFPA 101 2012 Edition.

An interview with Staff A (Corporate Manager, Facility and Operations) and Staff B (Supervisor, Fire and Life Safety) on 12/12/ 2017 at 2:30 PM, confirmed this finding.

Based on observation and staff interview, the facility failed to ensure that intervening rooms have no hazardous areas, and hazardous areas within the suites comply with section NFPA 101-2012 edition Life Safety Code 19.2.5.7.1.3.

Findings:

During a tour of the facility on 12/11/2017 at approximately 12:16 PM, the following was observed:

The facility stored large quantity of Operating room equipment and materials (e.g. linen, surgical materials, gloves, needles and syringes, wheel chairs, weighing scales etc.) in the large alcove of Suite S-16, in the pre-operating area.

Large quantity of Operating room equipment and materials (e.g. linen, surgical materials, gloves, needles and syringes, wheel chairs, weighing scales etc.) were stored in the large alcove of Suite S-17, in the operating suite area.

Large quantity of Operating/ PACU materials (e.g. linen, surgical materials, gloves, syringes, wheel chairs, weighing scales etc.) were stored in the large alcove of Suite S-7, in the post-operating area.

Concurrent interviews with Staff A (Corporate Manager, Facility and Operations) and Staff B (Supervisor, Fire and Life Safety) on 12/11/2017 at 12:32 PM, confirmed these findings.

Based on observation and staff interview, the facility did not ensure that Exit and directional signs are displayed in accordance with 7.10 and continuous illumination also served by the emergency lighting system.
19.2.10.1.

Findings include:

The receiving area of the loading duct on the 1st floor, did not have an illuminated exit sign.

The gas manifold storage room on the 1st floor, did not have an illuminated exit sign.

These findings were identified in the presence of Staff E, Vice President; Staff D, Manager; Staff L, Safety Emergency Coordinator, and brought to the attention of the hospital's leadership during the exit conference.

Based on observation and staff interview, the facility did not ensure that all fire rated walls are properly enclosed with construction providing the fire resistance rating as per the architectural drawings and NFPA 101 requirements.

Findings includes:

During a tour of the facility on the morning of 12/13/2017, the following was identified in the presence of Staff E, Vice President; Staff D, Manager; Staff L, Safety Emergency Coordinator, who acknowledged the finding.

The one hour fire rated wall above the entrance door of the Neonatal Intensive Care Unit (NICU) was found to have some penetrations that were not sealed by a fire stops.

Based on observation, staff interview and document review, the facility failed to ensure that: (a) the fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code, and (b) records of system acceptance, maintenance and testing are readily available.

Finding:

On 12/13/2017 at approximately 12:00 PM during document review, it was revealed that the facility did not have any documented record of smoke detector sensitivity testing as required.

An interview with Staff A (Corporate Manager, Facility and Operations) and Staff B (Supervisor, Fire and Life Safety), on 12/13/2017 at 12:20 PM, confirmed this finding. During the interview, it was stated that stated that they are not aware of this testing requirement.

Based on observation and staff interview, the facility did not ensure that the Elevator machine room is protected by an approved automatic sprinkler system in accordance with NFPA 13.

Findings includes:

During a tour of the 1st floor of the hospital, on 12/12/2017 at approximately 10:55 AM, the following were identified in the presence of Staff E (Vice President), Staff D (Manager), Staff L (Safety Emergency Preparedness Coordinator), who acknowledged the finding.

The elevator machine room was observed to have no sprinkler protection. When asked, the facility staff said that the hospital is fully sprinklered and did not know why this room had no sprinkler coverage.

The dry food storage room was found to have boxes stored very close to the ceiling tiles, not leaving 18 inches between the stored items and the ceiling.

Based on observation and staff interview, the facility failed to ensure that Automatic Sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of water-based Fire Protection Systems.

Findings:

On 12/12/2017 at 11:30 AM, it was observed that a concealed Sprinkler head lacked escutcheon cover plate in the Cat Scan Room #1, in the S15.

A concurrent interview with Staff A (Corporate Manager, Facility and Operations) and Staff B (Supervisor, Fire and Life Safety), on 12/12/2017 at 11:30 AM, confirmed this finding.


On 12/15/2017 at approximately 11:12 AM, it was observed:
The facility did not have two (2) spare of upright sprinkler heads in the spare cabinet located at the sprinkler system room at the extension clinic of the Hospital at 200 Westage Business Center in Fishkill, New York.

The facility did not have a battery backup light in the sprinkler system/fire pump system as required at the extension clinic of the Hospital at 200 Westage Business Center in Fishkill, New York.

An interview with Staff A on 12/15/2017 at 11:14 AM confirmed these findings.

Based on observation and staff interview, the facility failed to ensure that portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, standard for Portable Fire Extinguishers.

Findings:

On 12/12/2017 at 11:27 AM, a water based portable fire extinguisher was observed to be stored on the floor of the Cat Scan equipment control room, in Suite S15 on the second floor.

A concurrent interview with Staff A (Corporate Manager, Facility and Operations) and Staff B (Supervisor, Fire and Life Safety), on 12/12/2017 at 11:27 AM, confirmed this finding.

Based on observation and staff interview, the facility failed to ensure that smoke barriers are constructed to a ½ hour fire resistance rating, per NFPA 101-2012 edition of Life Safety Code 8.5.

Findings:

On 12/10/2017 approximately at 2:30 PM, the following was observed:

A cable penetration of the 1 hour fire/smoke barrier wall was observed above the 1 hour fire door in the vicinity of the GI laboratory.

A hole, approximately 3 inches in radius was observed in the 2 hour fire/smoke wall in the vicinity of the non-sterile Operating room corridor.

A concurrent interview with Staff A (Corporate Manager, Facility and Operations) and Staff B (Supervisor, Fire and Life Safety) on 12/10/ 2017 confirmed these finding.



On 12/12/2017 at approximately 10:23 AM, and at 12:02 PM ,the following was observed:

An unsealed conduit penetration, approximately 3 inches wide was observed in the smoke barrier door in the vicinity of the Neuro-Interventional Surgery Unit on the second floor of the facility.

Two (2) holes, approximately 4 inches by 4 inches and 4 inches by 5 inches, were observed in the 2-hour fire/smoke barrier wall in the vicinity of Operating Room corridor, by Exam Room 18.

Concurrent interview with Staff A (Corporate Manager, Facility and Operations) and Staff B (Supervisor, Fire and Life Safety), confirmed these findings.



On 12/15/2017 at 10:54 AM, the following was observed:

Two (2) conduits and two (2) cable penetrations of the 1 hour demising wall separating the facility extension clinic from other tenants at 200 Westage Business Center.

One (1) hole, approximately 4 inches by 4 inches and 3 cable penetrations on the 1 hour fire barrier wall by the waiting area of the facility extension clinic.

Concurrent interview with Staff A, confirmed these findings.

Based on observation and staff interview, the facility did not ensure portable space heating device are prohibited in all health care occupancies unless in non-sleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius).

Findings:

On 12/10/2017 at 12:10 PM, three (3) portable space heating device were observed in the Medical Record office area on the second floor of the hospital. At the time of the survey, the heating element of these portable heating devices cannot be verified.

An interview with Staff A (Corporate Manager, Facility and Operations) and Staff B (Supervisor, Fire and Life Safety) on 12/12/ 2017 at 12 :11 PM confirmed this finding.

Based on observation and staff interview, the facility did not ensure that electrical equipment are maintained in good operating condition.

Findings include:

During a tour of the facility on 12/10/2017 at approximately 12:15 PM, the following was observed:

Three (3) electrical junction boxes were opened (lacked cover plate) above the ceiling in the vicinity of the pre-operating holding area on the second floor of the facility.

An emergency electrical receptacle labeled "2WWECRA 317" in the pre -operating holding area was broken.

A concurrent interview with Staff A (Corporate Manager, Facility and Operations) and Staff B (Supervisor, Fire and Life Safety), confirmed these findings.



On 12/12/2017 between the hours of 11:40 AM to 3:15 PM, the following was observed:

One (1) unlabeled/unidentified electrical panel was observed in the electrical closet in Suite 15- Radiology Department.
One (1) unlabeled/unidentified electrical panel was observed in the electrical closet in Suite 5, on the second floor of the facility.
Panel J, panel JEP, and panel JB in electrical closet in Cath Laboratory step-down area, lacked panel directory.
A missing blank (plastic cover for one of the panel breaker) was observed in the unlabeled panel in the electrical closet in Suite 5.

Concurrent interview with Staff A (Corporate Manager, Facility and Operations) and Staff B (Supervisor, Fire and Life Safety), confirmed these findings.



On 12/13/2017 between the hours of 10:28 AM to 11:35 AM, the following was observed:

One (1) electrical junction box was observed to be opened (lacked cover plate) in the mechanical room at the basement of the facility.
One (1) electrical junction box was observed to be opened (lacked cover plate) above the ceiling in the vicinity of pediatric waiting area in the fourth floor of the facility.
Two (2) missing blanks (plastic cover for two of the panel breaker) were observed in panel 4LPC on the fourth floor.
Panel L behind the nursing station in the Respiratory Care Unit on the fourth floor, lacked panel directory.

Concurrent interview with Staff A (Corporate Manager, Facility and Operations) and Staff B (Supervisor, Fire and Life Safety), confirmed these findings.


On 12/14/2017 at 11:58 AM, it was observed that panel LPER at the basement of the facility lacked panel directory.
On 12/14/2017 at 12:47 PM, 3 missing blanks (plastic cover for three of the panel breaker) were observed in panel LEE-6A on the sixth floor, General Medical Surgical area.

Concurrent interview with Staff A (Corporate Manager, Facility and Operations) and Staff B (Supervisor, Fire and Life Safety), confirmed these findings.




On 12/15/2017 at 9:40 AM, three (3) electrical junction boxes were observed to be opened (lacked cover plate) in the mechanical room at the facility extension clinic (Ambulatory Surgery Center) located at 200 Westage Business Center, Fishkill, New York.
A concurrent interview with Staff A (Corporate Manager, Facility and Operations) confirmed these findings.

Based on observation, staff interview and document review, the facility: (a) failed to ensure that hospital grade electrical receptacles and the non-hospital grade electrical receptacles are tested at a regular interval, defined by documented performance data and manufacturer's instruction, (b) did not provide documented evidence that the Ground Fault Circuit Interrupter (GFCI) receptacles are tested monthly as per the manufacturer's instructions..

Findings:

On 12/10/2017 between 12:00 PM and 3:30 PM , observations made during the tour of the facility revealed that the facility had installed hospital grade electrical receptacles and Ground Fault Circuit Interrupter (GFCI) receptacles at various locations in the hospital.

The facility did not provide documented evidence of any testing performed on these receptacles, in accordance with the manufacturer's instructions on testing.

An interview with Staff A (Corporate Manager, Facility and Operations) and Staff B (Supervisor, Fire and Life Safety), on 12/11/2017 at approximately 2:00 PM, confirmed that the facility is not testing these electrical receptacles because they were not aware of the requirement.

Based on observation and staff interview, the facility failed to ensure that the Essential Electrical System (EES) are properly installed and that the EES system loads are not mixed up at the distribution level.

Findings include but not limited to the following examples:

On 12/11, 12/12, 12,13, 12/14 and 12/15/2017, during the tour of the facility and review of several EES (Life Safety, Critical and Equipment branches) panel directories, it was observed that the electrical load were found mixed on the three EES branches at the distribution levels.

Examples include but not limited to:

Panel labeled OR-1(The facility was not sure which branch of EES it is) on the second floor had critical loads on it and also contained a life safety load e.g. Medical Gas Alarm panel

Panel labeled OR-4(The facility was not sure which branch of EES it is) on the second floor had critical loads on it and also contained a life safety load on it e.g. Exit Lights

Panel labeled EEQ1(Equipment Branch of EES) on the 4th floor of the hospital that had equipment loads, but also contained some life safety loads e.g. Medical Gas Alarm panel and Fire Dampers on it.

Panel labeled L (Critical and Life safety branch of EES according to facility) on the 4th floor of the hospital in the Respiratory Care Unit, also contained some life safety loads e.g. Medical Gas Alarm and smoke duct Damper.

Panel labeled LP-ER4 SC4(critical Branch of EES) on the 4th floor of the hospital contained some life safety loads on it e.g. Exits lights, Medical Gas Alarm panel.

Panel labeled LP-EE SC5 (Critical Branch of EES) on the 5th floor of the hospital contained some life safety loads on it e.g. Medical Gas Alarm Panel, Exits lights.

Panel labeled APCE7A SC7 (Normal Power) on the 7th floor of the hospital contained some life Safety loads and critical loads on it e.g. smoke dampers, Fire Alarm door holders, nurse call system.

Panel labeled APCE6A SC6 (Normal Power) on the 6th floor of the hospital contained some life Safety loads and critical loads on it e.g. smoke dampers, Fire Alarm door holders, nurse call system.

An interview with Staff A (Corporate Manager, Facility and Operations) and Staff B (Supervisor, Fire and Life Safety) on 12/15/2017 at approximately 12:30PM, confirmed these findings.

Based on observation and staff interview, the facility did not ensure that all power strips are used with general precautions, and extension cords are not used as a substitute for fixed wiring of a structure.

Findings:

On 12/12/2017 at 12:15 PM, five (5) extension cords were observed to be serially connected to each other, with at least two (2) extension cords connected serially (5 Daisy Chained) in the Medical Record area of the second floor of the hospital.
A concurrent interview with Staff A (Corporate Manager, Facility and Operations) and Staff B (Supervisor, Fire and Life Safety), confirmed this finding.


On 12/13/2017 at 11:26 AM, two (2) extension cords were observed to be serially connected (2 Daisy Chained) in Room 409 (vicinity of Respiratory Unit), on the 4th floor of the hospital.
Concurrent interview with Staff A (Corporate Manager, Facility and Operations) and Staff B (Supervisor, Fire and Life Safety), confirmed this finding.