HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure that stairways and smoke proof enclosures used as exits are maintained in accordance with section 7.2 of NFPA 101-2012 Life Safety Code.

This finding represents the potential for patient harm due to fire and smoke exposure.

Findings include:

On 06/06/2017 at 1215 PM, a cable penetration was observed on the wall of room T 736 into the stairways. A concurrent interview with the Director of Engineering on 06/06/2017 at 1215 PM, staff S confirmed this finding.

On 06/06/2017 at 3:15 PM, 2 cable penetrations and one conduit penetration were observed at the exit access enclosure at the bottom landing of stair D. A concurrent interview with staff S on 06/06/2017 at 3:15 PM confirmed these findings.

Based on observation and staff interview, the facility failed to ensure that an emergency lighting of at least 1.5 hours duration is provided automatically in accordance with 7.9.

This finding represents the potential for patient harm due to inability to evacuate in an emergency situation where power is lost.

Findings include:

On 06/06/2017 at 3:30 PM, it was observed that there was no emergency exit lights in the horizontal exit by stair case D in the vicinity of the Emergency Department. A concurrent interview with staff S, Director of Engineering on 06/06/2017 at 3:30 PM confirmed this finding.

Based on observation and staff interview, the facility failed to ensure that hazardous areas are protected by a fire barrier having at least 1 hour fire resistance rating (with ¾ hour fire rated doors).

This finding represents the potential for patient harm due to risk of fire.

Findings include:

On 06/06/2017 at 10:30 AM, multiple cable and conduit penetrations, not less than 4 were observed inside a non-sprinklered electrical closet T 748. A concurrent interview with staff S on 06/06/2017 at 10:30 AM confirmed this finding.

On 06/09/2017 at 3:15 PM, four (4) conduit penetrations were observed in the main electrical room at the basement of the facility. In addition, the non -sprinklered room had no self-closing device on the door. A concurrent interview with staff S on 06/09/2017 at 3:15 PM confirmed this finding.

On 06/08/2017 at 11:42 AM, four (4) cable penetrations and one hole, approximately 8 inches by 8 inches were observed inside storage room CP 225. A concurrent interview with staff S on 06/08/2017 at 11:42 AM confirmed these findings.

On 06/12/2017 at 10:05 AM, it was observed that the facility stored medical record in an non fire-rated room (the wall did not go up to the roof deck, there was no self-closing device on the door and the door did not have any evidence of fire-rating) in the Outpatient clinic, located across the hospital. The building does not have an automatic sprinkler system. A concurrent interview with staff S on 06/12/2017 at 10:05 AM confirmed this finding.

Based on observation and staff interview, the facility failed to ensure that manual fire alarm pull stations are provided in the path of egress near each required exit and is easily accessible.

This finding represents the potential for patient harm due to risk of failure to initiate proper notification of a fire condition.

Finding include:

On 06/05/2017 at 11:25 AM during the tour of the kitchen, it was observed that the facility stored 3 unused refrigerators directly in front of the fire alarm pull station, thereby obstructing the accessibility to the pull station. An interview with the Director of Food Service department, staff X and Assistant Director Food Service department Staff Y on 06/05/2017 at 11:27 AM confirmed this finding.

Based on interview and observation, the facility failed to ensure that fire alarm system is tested and maintained in accordance with approved program complying with the requirement of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and signaling Code.

Finding include:

On 06/07/2017 at 2:07 PM. It was observed that the magnetic door holder of the smoke door outside the Adult Psychiatric unit located on CP4 was damaged (hanging loose on the wall fixture). A concurrent interview with staff S on 06/07/2017 at 2:07 PM confirmed this finding.

Based on observation and staff interview, the facility did not ensure that automatic sprinkler system are inspected, tested and maintained in accordance with NFPA 25, Standard for the Inspection, Testing and Maintaining of Water-based Fire Protection Systems.

This finding represents a potential for patient harm due to risk of sprinkler failure which could to rapid spread of fire.

Findings:

On 06/05/2017 at 11:40 AM, a heavy built up of dust was observed on the pendant sprinkler head inside freezer 2 located in the food preparatory area of the facility. A concurrent interview with the Assistant Director of Food Service, staff Y on 06/05/2017 at 11:40 AM confirmed this finding.

On 06/05/2017 at 11:36 AM, it was observed that the concealed sprinkler head in the vicinity of freezer 3 located in the food preparatory area of the facility lacked escutcheon cover plate. A concurrent interview with staff Y on 06/05/2017 at 11:36 AMconfirmed this finding.

On 06/05/2017 at 11:30 AM and 11:39 AM, it was observed that there was no sprinkler heads inside the vegetable walk in freezer and freezer #3 in the food preparatory area of the facility. A concurrent interview with staff Y on 06/05/2017 at 11:30 AM confirmed these findings.

On 06/05/2017 at 11:42 AM, it was observed that 3 concealed sprinkler heads in the food preparation area lacked escutcheon cover plate. A concurrent interview with staff Y on 06/05/2017 at 11:42 AM confirmed these findings.

On 06/07/2017 at 10:55 AM, it was observed that the concealed sprinkler head in the Nurse Locker room and lounge in the vicinity of room T 309 lacked escutcheon cover plate. A concurrent interview with the Director Of Engineering, staff S on 06/07/2017 at 10:55 AM confirmed this finding.

On 06/07/2017 at 3:20 PM, it was observed that the concealed sprinkler head in front of room T 429 was missing escutcheon cover plate. A concurrent interview with staff S on 06/07/2017 at 3:20 PM confirmed this finding.

On 06/08/2017 at 11:17 AM, it was observed that the concealed sprinkler head in room T 205 lacked an escutcheon cover plate. A concurrent interview with staff S on 06/08/2017 at 11:17 AM confirmed this finding.

On 06/12/2017 at 2:33 PM, it was observed that the concealed sprinkler head in front room T 420 lacked an escutcheon cover plate. A concurrent interview with staff S on 06/12/2017 at 2:33 PM confirmed this finding.

On 06/06/2017 at 3:15 PM, it was observed that 2 copper piping were improperly attached with a chain like device to a sprinkler pipe above the ceiling at the exit passageway of stair D in the first floor. A concurrent interview with staff S on 06/06/2017 at 3:15 PM confirmed this finding.

On 06/09/2017 at 11:45 AM, it was observed that the facility did not store the required number of spare sprinkler heads of each type that is installed in the facility. Observations in the sprinkler/ fire pump room revealed that the facility did not have at least 2 spare sprinkler heads of each type installed in the facility. A concurrent interview with staff S on 06/09/2017 at 11:45 AM confirmed this finding.

On 06/13/2017 between the hours 11:00 AM and 12:00 noon, it was observed that the facility did not install sprinkler heads at the top and bottom landing of all the exit stair wells (stairwell 11E, 11D, 5B, 5C, 1E, 1B, 1A, 1C, 3A and 1D) in the facility. A concurrent interview with staff S on 06/13/2017 at approximately 11:30 AM confirmed these findings.


On 06/13/2017 at approximately 10:35 AM during record review, it was revealed that the facility did not have a documented evidence of required monthly fire pump churn test. An interview with staff T, Vice-President of Facilities on 06/13/2017 at 10:38 AM confirmed this finding and the document revealed that the last fire pump churn test was last performed in August, 2016.

Based on observation and staff interview, it was observed that the facility failed to ensure that smoke barriers are constructed to a ½ hour fire resistance rating per 8.5

This finding represents the potential for patient harm due to risk of rapid spread of fire within the facility.

Findings include:

On 06/06/2017 at 11:45 AM, four (4) conduit penetrations of the 1- hour fire/smoke barrier wall was observed in the vicinity of storage room T 733

On 06/06/2017 at 11:56 AM, it was observed that the top of the wall joint assembly forming part of the 1-hour fire/smoke wall inside room T 706 was not fire-stopped. A concurrent interview with staff S on 06/06/2017 at 11:56 AM confirmed this finding.

On 06/06/2017 at 12:08 PM, one conduit penetration and 2 unsealed cable penetration were observed above the fire/smoke door T 744. A concurrent interview with staff S on 06/06/2017 at 12:08 PM confirmed this findings.

On 06/06/2017 at 12:10 PM, five (5) cable penetrations were observed on the 1-hour fire/smoke barrier wall inside room T 716. A concurrent interview with staff S on 06/06/2017 at 12:10 PM confirmed this findings.

On 06/06/2017 at 3:37 PM, unsealed duct angle hole was observed above the fire/smoke door in the vicinity of the Coronary Care Unit (CCU). A concurrent interview with staff S on 06/06/2017 at 3:37 PM confirmed this finding.

On 06/06/2017 at 4:11 PM, four (4) hole, approximately 4 inches by 4 inches, 4 inches by 6 inches, 6 inches by 8 inches and 8 inches by 8 inches were observed on the 1-hour fire / smoke barrier wall in room T 330. A concurrent interview with staff S on 06/06/2017 at 4:11 PM confirmed these findings.

On 06/06/2017 at 4:15 PM, one unsealed cable penetration was observed on the 1-hour fire/smoke wall above the fire/smoke door in the vicinity of room T 730. A concurrent interview with staff S on 06/06/2017 at 4:15 PM confirmed this finding.

On 06/07/2017 at 10:35 PM, the top of the joint assembly of the 1 hour fire/smoke barrier was observed not to be sealed from room T 327. In addition, not less than half a dozen conduit penetrations of the 1-hour fire/smoke wall were observed in the vicinity of room T 327. A concurrent interview with staff S on 06/07/2017 at 10:35 PM confirmed these findings.

On 06/07/2017 at 10:49 AM, it was observed the facility inappropriately fire stopped around the 2 separate ducts penetrating the 1 hour fire/smoke barrier wall in the vicinity of door T 309, instead of sealing the penetration with metal angles. A concurrent interview with staff S on 06/07/2017 at 10:49 AM confirmed these findings.

On 06/07/2017 at 11:03 AM, it was observed that the facility did not fire-proof the top of the wall joint assembly that formed the 1-hour fire /smoke assembly located in the vicinity of room T 333. A concurrent interview with staff S on 06/07/2017 at 11:03 AM confirmed this findings.

On 06/08/2017 at 11:35 AM, two conduit penetrations were observed in the smoke wall in the vicinity of room CP 226. A concurrent interview with staff S on 06/08/2017 at 11:35 AM confirmed these findings

On 06/06/2017 at approximately 4:15 PM, it was determined that the current life safety drawings presented by the facility to the surveyor were not accurate, in that it did not indicate clearly the locations of the smoke/ fire walls in the building. This was clearly noted on floor 3 and floor 9. A concurrent interview with the Vice-President of facilities, Staff T on 06/06/2017 at approximately 4:15 PM confirmed these findings.

Based on observation and staff interview, it was observed that the facility failed to ensure that electrical wiring and equipment complies with NFPA 70, National Electric Code.


Findings:

On 06/07/2017 at 10:35 AM, a temporary light was observed above the suspended ceiling in room 327. A concurrent interview with staff S on 06/07/2017 at 10:35 AM confirmed this finding.

On 06/07/2017 at 11:48 AM, a temporary light was observed above the suspended ceiling in room T 313. A concurrent interview with staff S on 06/07/2017 at 11:48 AM confirmed this findings.

On 06/07/2017 at 12:00 PM a temporary light was observed above the suspended ceiling in the soiled utility room by the nursing station the pediatric unit. A concurrent interview with staff S on 06/07/2017 at 12:00 PM confirmed this findings.

On 06/07/2017 at 12:00 PM, an electrical junction box was observed to lack a cover plate. A concurrent interview with staff S on 06/07/2017 at 12:00 PM confirmed this finding.


On 06/07/2017 at 2:50 PM, one unlabeled electrical panel was observed inside room CP 403. A concurrent interview with staff S on 06/07/2017 at 2:50 PM confirmed this finding.

On 06/08/2017 at 12:45 PM, two electrical panels labeled ELCR2 and LRP2 on the second floor located in the vicinity of the stair leading to the utility building were observed to lack directory. A concurrent interview with staff S on 06/08/2017 at 12:45 PM confirmed these findings.


On 06/08/2017 at 10:55 AM, two open junction boxes were observed to lack cover plates above the suspended ceiling of an electrical room, located in the vicinity of the exit stairs leading to the utility building. A concurrent interview with staff S on 06/08/2017 at 10:55 AM confirmed these findings.

Based on observation and staff interview, it was observed that the facility failed to ensure that portable space heating devices are prohibited in all health care occupancies.
This finding represents the potential for patient harm due to risk of fire.

Findings include

On 06/07/2017 at 3:10 PM, a portable space heater each was observed in the office of the Therapist CP 403. A concurrent interview with staff S on 06/07/2017 at 3:10 PM confirmed this finding

On 06/07/2017 at 3:15 PM, a portable space heater was observed in the office of the Unit Chief (Psychiatrics department) CP 403. A concurrent interview with staff S on 06/07/2017 at 3:15 PM confirmed this finding

On 06/07/2017 at 3:20 PM, a portable space heater was observed in the office of the Psychologist CP 403. A concurrent interview with staff S on 06/07/2017 at 3:20 PM confirmed this finding

0n 06/12/2017 at 10:30 AM, two portable space heaters were observed in the medical records unit by the staff desk, for which the maximum temperature of the heating elements could not be verified, to ensure that it did not exceed 212 degree Fahrenheit (100 degrees Celsius). A concurrent interview with staff S on 06/12/2017 at 10:30 AM at this time confirmed this finding.

Based on observation and staff interview, the facility failed to protect the Operating rooms with ground fault circuit interrupters(GFCI).

Findings include:

On 06/08/2017 at approximately 10:30 AM, it was observed that the operating rooms did not have a ground fault circuit interrupters (GFCI) receptacles and/or the receptacles were not on isolated power. The hospital did not provide documented evidence of risk assessments for the operating rooms (OR). Interview of the facility electrician on 06/13/2017 at approximately 11:00 AM confirmed the lack of GFCIs in the ORs. The Vice-President of facilities, Staff T on interview on 06/13/2017 at approximately 11:15 AM, stated that the hospital was not aware of the need for risk assessment to determine whether the operating rooms were to be considered as wet locations.

Based on record review and staff interview, the facility failed to ensure that there was a documented evidence of any testing and maintenance performed of the Line Isolation Monitor (LIM) installed in the operating rooms.

This finding represents a potential for patient harm in the event of fire.

Finding: include:

On 06/13/2017 at approximately 1:00 PM, during facility document review, it was revealed that the facility failed to provide documented evidence of any testing and maintenance performed on the Line Isolation Monitor (LIM). An interview with facility's Electrician, staff U, on 06/13/2017 at 1:45 PM confirmed this finding.

Based on observation, documentation (i.e., Panel Board Schedule) review and interview, the facility's Type 1 Essential Electrical System Distribution was not separated into Critical Branch, Life Safety Branch and Equipment branches in accordance with NFPA 99. This was noted in the distribution panels located on the 2nd and 3rd floor of the Tower building.

Findings include but not limited to:

(a) On 06/08/17 at approximately 11:00 AM, review of the load distribution in the Emergency Electrical Panel "ELLS 2" located on the 2nd Floor of the Tower building, revealed that the panel served the Life Safety branch (e g Medical Gas Alarm, Intercom) and the Equipment branch (e.g. Translogic machine)

(b) On 06/06/17 at approximately 3:30 PM, review of the load distribution in the Emergency Electrical Panel "ELLS-3" located on the 3rd Floor of the Tower building, revealed that the panel served the Life Safety branch (e.g. Corridor light, exit light, Medical Gas Alarm) and the Critical branch (e.g. ICU receptacles, Nurse call ).

(c) On 06/13/17 at approximately 12:00 noon, review of the load distribution in the Emergency Electrical Panel "ELPP- 6" located in the mechanical room on the 6th Floor of the Tower building revealed that the panel served the Life Safety branch (exit light of the mechanical room) and the Equipment branch (e.g Exhaust fan).

These observations were confirmed with the facility's electrician, Staff U on 06/13/17 at approximately 12:30 PM.
Upon interview of the Vice President of Facilities, Staff T on 06/13/17 at approximately 1:00 PM, it was stated that the facility did not have any waivers requested on file for the Essential Electrical System.
.

Based on observation and staff interview, the facility failed to provide a remote annunciator that is storage battery powered to operate outside of the generating room, in a location that readily observed by operating personnel.

Finding include:

On 06/12/2017 at 1:30 PM, during the tour of the mechanical/generator room, located in the utility building, it was revealed that the facility did not install remote annunciators for any of the two emergency generators.

Interview of Staff S on 06/12/2017 at approximately 1:35 PM, confirmed that the facility did not have any remote annunciators for the generators.

Based on observation and staff interview, the facility failed to ensure that battery powered back-up lights were provided in the facility's Operating rooms, fire pump room and the generator room.

Findings include:

On 06/08/17 at approximately 10:30 AM, tour of the Operating Room #1 revealed that the operating room did not have a battery powered back-up light, to ensure adequate lighting in case of normal power and generator failure.

This situation was also observed in the 2 Labor and Delivery Rooms.

Upon interview Staff S, the Director of Engineering on 06/08/17 at approximately 2:00PM, it was stated that the 8 Operating rooms and the 2 Labor and Delivery rooms were not provided with battery powered back-up lights.

On 06/09/2017 at 11:45 AM, it was observed that the facility did not have battery powered back-up lights inside the fire pump room and the electrical room in the facility.

An interview with staff S on 06/09/2017 at 11:45 AM, Director of Engineering confirmed these findings.

Based on observation, staff interview and record review, the facility failed to ensure that Power strips are used with general precaution and as stated in the facility's policy and procedure.

Findings include:

On 06/07/2017 at 2:20PM, it was observed that an extension cord was connected serially into another extension cord by the nursing station in room CP 410 in the Psychiatric Unit.

On 06/13/2017 at 1:30PM, it was observed that 2 electrical extension cord were observed to be serially connected into each other in the facility Laboratory room CP 303.

Review of the facility's policy on the use of adapters and extension cords dated 1/1/2014 on 06/13/17 at approximately 1:00 PM, revealed that the use of daisy chain adapters were prohibitted in the facility.

An interview with staff S on 06/13/17 at approximately 1:15 PM confirmed that the staff of the facility was not allowed to use adapters and extension cords without permission from the Department of Engineering..

Based on review of documents and staff interview, the facility failed to ensure that electrical safety tests were performed on all patient-care related electrical equipment used in the facility.

Specific reference is made to the radiological equipment installed at the facility.

Findings include:

During review of Preventative Maintenance records for the CT Scan, MRI and the X-ray equipment on 06/13/17 at approximately 2:30 PM, the surveyor noted that the facility did not have any documented evidence of any electrical safety tests performed at least annually.

Upon interview, the Director of Radiology on 06/13/17 at approximately 3:00 PM, it was confirmed that there was no record of the physical integrity, resistance and leakage current availble for any of the radiological equipment.