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Based on observation and interview, the facility failed to maintain all exit access and exit locations in accordance with NFPA 101, 2012 ed., 19.2.1 and Chapter 7.

The findings include:

a) During the site visit of 5/8/2018, at approximately 11:15 AM., it was observed that Exit Stair C at the rear of the kitchen, in the basement of the Guggenheim Pavilion Building required egress through an intervening space that did not meet the requirements of an exit enclosure. The intervening space contained an opening to a mechanical room which houses the electrical feeders and transformers supplying power to the building. The space also contained an electrical panel closet.
Per NFPA 101, 2012 edition, 7.1.3.2.1(9) (c) (ii)(iii) existing openings to mechanical equipment spaces must contain no storage of combustibles, and must be located in a building protected throughout by an approved automatic sprinkler system. The Guggenheim Pavilion Building is not sprinkler protected throughout.
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Upon interview on 5/9/18 at approximately 10:00 AM, Staff N, Vice President of Operations Engineering Department, stated that the stairwell in the kitchen was not a required means of egress. He stated that the kitchen had 4 egress access doors other than the stairwell door, and that there were three other stairwells serving as egress from the basement. These statements were verified by surveyor observation on 5/9/18 at approximately 11:25 AM

Any door, passage or stairway that is neither an exit nor a way of exit, and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads "No Exit" in accordance with NFPA 101, 2012 ed., 7.10.8.3.1 and 7.10.8.3.2.


These findings were verified at the time of observation to Staff M, Director of Engineering Mt. Sinai Manhattan; Staff N, Vice President of Operations Engineering Department and Staff H, Senior Vice President Mt. Sinai Health Systems.

Based on observation and interview, the facility failed to ensure that the door to a hazard area was self-closing and kept in the closed position in accordance with NFPA 101, 2012 ed. 19.3.2.

The findings include:

During the site visit of 5/8/2018 at approximately 11:20 AM, the door to the electrical room behind the kitchen in the Guggenheim Pavilion Building basement did not self-close or automatically close, and did not remain in the closed position when released.

Staff M, Director of Engineering Mt. Sinai Manhattan, acknowledged the door to the electrical room, which houses electrical transformers and the main electrical feeders to the building, should self-close.

This finding was verified at the time of observation by Staff M, Director of Engineering and Staff H, Senior Vice President Mt. Sinai Health Systems.

Based on observation, document review and staff interview, the facility did not ensure that not less than two (2) exits, remote from each other, and accessible from every part of every story are provided for each story. Each smoke compartment shall likewise be provided with two (2) distinct egress paths to exits that do not require the entry into the same adjacent smoke compartment

Finding:

On 05/09/2018 at 12:50 PM, it was observed that the two (2) stairs A and B on the 6th floor are in the same smoke compartment and are not remote from each other.

Upon review of Life Safety Plan and documents on 05/10/2018, it was noted that the facility had conducted a FSES (Fire Safety Evaluation System) analysis and obtained a passing score as an equivalency in 2013. However, the facility did not provide documents with an updated FSES analysis of all areas in the old building.

An interview with Staff B, Director of Engineering and Staff C, Assistant Director of Engineering, on 05/10/2018 confirmed this finding.

Based on observation, document review and staff interview, the facility did not ensure that suites more than 1,000 ft² shall have two (2) or more remote exits. One means of egress from the suite shall be to a corridor and one may be into an adjacent suite separated in accordance with corridor requirements.

Finding:

On 05/09/2018 at approximately 12:45 PM, it was observed that the intensive care unit (ICU) on the six (6) floor of the old building which is approximately 2,776 sq ft had only one (1) exit from the suite.

Upon review of Life Safety Plan and documents, it was noted that the facility had conducted a FSES (Fire Safety Evaluation System) analysis and obtained a passing score as an equivalency in 2013. However, the facility did not provide documents with an updated FSES analysis of all areas in the old building.

An interview with Staff B, Director of Engineering and Staff C, Assistant Director of Engineering, on 05/10/2018 at 12:47 PM, confirmed this finding.

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

Finding includes:

On 5/12/2018 at approximately 11:00 AM, during a tour of the Robotic Pharmacy, it was observed that there was no exit sign to direct the staff to the exit door in the event of fire or smoke condition.

This finding was identified in the presence of Staff N, VP Operations Engineering.

Based on observation and staff interview, the facility did not ensure to adequately safeguard the hazardous areas by enclosing them with a 1-hour fire resistive barrier or providing with an automatic extinguishing system in accordance with 8.7.1
Specific reference is made to the electrical room in the ICU and the electrical room in the new emergency room (ED) area.

Findings include:

Queens Campus:
During the tour of the facility on 05/07/2018 at approximately 11:30 AM, the surveyors noted that the renovated electrical room in the new ED area did not have sprinkler protection. The door assembly of the room was rated for 45 minute fire resistance. The facility was not able to verify the enclosure rating through the Life Safety plans or other documents.

On 05/09/2018 at approximately 12;00 noon, it was observed that the electrical room in the ICU unit of the old building did not have One (1) hour fire rated enclosure and/or was not provided with sprinkler protection.

Upon interview of the Assistant Director Of Engineering, Staff C on 05/09/2018 at approximately 3:00PM, staff acknowledged the finding.

Based on observation and staff interview, the facility failed to ensure that buildings are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

Finding:

Queens Campus
On 05/11/2018 at 12:30 PM, it was observed that the facility did not have a sprinkler head at the top of the shaft of Stair C and under the first accessible landing above the bottom of the shaft of Stair C in the facility's new building, which is fully sprinkler protected.

An interview with Staff C, Assistant Director of Engineering, at approximately 12:36 PM, confirmed this finding.

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 Maintaining of Water-based Fire Protection Systems.

Findings:

Queens Campus:
On 05/07/2018 at 12:22 PM, a damaged upright sprinkler head was observed (the flat metal head was bent) in the kitchen.
An interview with Staff B, Director of Engineering and Staff C, Assistant Director of Engineering on 05/07/2018 at 12:25 PM, confirmed this finding.


Manhattan Campus
During the tour of the facility on 5/07/18 and 05/09/2018, it was observed that some of the sprinkler escutcheon plates were painted over. Examples include (but not limited to):
(a) During the tour of Klingenstein Clinical Center on 5/7/18 at 12:00 PM, a sprinkler escutcheon plate was observed to be painted over in Storage Room C4-431.
(b) During the tour of Guggenheim pavilion on 5/08/2018 at 2:45 PM a sprinkler escutcheon was observed to be painted over in NH-116 patient restroom.

According to NFPA 13,6.2.6.2- Sprinklers shall only be painted by the sprinkler manufacturer. Where sprinklers have had paint applied by other than the sprinkler manufacturer, they shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.

Based on observation and interview, the facility failed to ensure that emergency system electrical receptacles in critical patient care areas were labeled in accordance with NFPA 101, 2012 ed., 9.1.2 and 19.5.1.1; NFPA 99, 2012 ed., 6.3.2.1; and NFPA 70, 2011 ed. 517.19.

Findings include:

During the tour at Mt. Sinai Manhattan, on 5/7/2018 between 11:30 AM. and 2:00 PM, and Mt. Sinai Queens on 5/8/2018 at 10:30 AM, it was observed that emergency receptacles at the following locations did not have a label indicating the panel board and circuit number supplying them, per NFPA 70, 2011 ed., 517.19:

(a) Mt. Sinai Manhattan Guggenheim Pavilion 5th floor North, Cardiac Catheterization Unit Post Anesthesia Care Unit (PACU). All PACU bay emergency receptacles lacked required identifying labels.

(b) Mt. Sinai Manhattan Guggenheim Pavilion 11th floor North, Oncology Amenities Unit. Receptacles at the head of patient beds in room N11-116 lacked identifying labels.

C) Mt. Sinai Queens 6th floor Intensive Care Unit (ICU). Emergency receptacles on the headwall at all seven patient beds in the ICU lacked identifying labels.

The findings at Mt. Sinai Manhattan were verified concurrently at the time of observation by Staff M, Director of Engineering Mt. Sinai Manhattan and Staff H, Senior Vice President Mt. Sinai Health Systems.

The findings at Mt. Sinai Queens were verified at the time of observation by Staff B, Director of Engineering Mt. Sinai Queens.

.Based on observation, documentation review and interview the old building at the Mt. Sinai Queens Campus did not have a compliant Type 1 Essential Electrical System (EES). This was noted during review of the electrical distribution panels located in the old Building and the review of load distribution schedule on the Automatic Transfer Switches.

Findings include:

During the tour of the facility's electrical room on 05/08/2018 at approximately 2:00 PM, it was revealed that there were total of nine (9) Transfer switches that served the old building.

Review of the connected load schedule revealed that the Life Safety Panel was connected to ATS (Automatic Transfer Switch) #2 along with other Critical Branch Loads.
In addition it was also noted that ATS (Automatic Transfer Switch) #1 served both the Critical branch and Equipment Loads.

Review of an electrical panel labeled as "LCE-1ER" revealed that the panel served critical branch loads (e.g. MRI control Room, MRI Holding Bed Receptacle, X-ray viewer etc.) and equipment branch load (Kitchen Compressor, A/C Unit IT Room #2)

The facility was not able to provide any other Riser Diagrams for the EES (Essential Electric System) in the old building.

Upon interview on 05/10/2018 at approximately 10:30AM, Staff B and Staff C confirmed that the old building at Mount Sinai Queens Campus did not have Type 1 EES (Essential Electric System) for their emergency power.