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Based on observation and staff interview, the facility failed to ensure safety to patients due to two sets of fire-rated doors in fire separation walls that did not fully close and latch in accordance with the requirement of NFPA 101 18.1.1.4.2, 18.2.2.7, 7.2.6.2. This deficient practice affected 2 of 11 smoke compartments.
Findings include
During a tour of the facility with Staff D (chief operations officer), and Staff MM (facility services director) between 3/05 - 3/07/12, Surveyor 12316 observed that (i) on 3/5/12 at 3:05 pm, one set of 1 ½-hr fire-rated cross-corridor double doors in the 2-hr fire-rated occupancy separation wall between the hospital and the Warren Street Clinic building on the 2nd Floor did not latch; and
(ii) on 3/7/12 at 9:19 am, one set of 1 ½-hr fire-rated cross-corridor double doors in the 2-hr fire-rated wall of exit passageway from the southwest Stairwell did not fully close and latch.

The above deficiency was acknowledged by the facility services director, and the chief operations officer at the time of discovery, and confirmed with the facility services director, the chief operations officer, and Staff HH (chief executive officer) at the time of exit conference on 3/7/2012 at 4 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients due to corridor walls of patient rooms not being smoke-tight and one space by the main entrance on the 1st Floor not separated by corridor wall in accordance with NFPA 101 18.3.6.2. This deficient practice affected 2 of 11 smoke compartments.
Findings include
During a tour of the facility with Staff D (chief operations officer), Staff MM (facility services director), and Staff PP (maintenance supervisor) between 3/5- 3/7/12, Surveyor 12316 observed that (i) on 3/5/12, all patient sleeping rooms in med surge units on the 3rd Floor, except rooms in the Obstetrics Unit, had nurse server cabinets built into the corridor walls, but the gaps around the cabinet doors were wide and did not limit the passage of smoke required for corridor walls; and
(ii) on 3/7/12 at 9:45 am, the wheel chair storage space between the patient waiting room and front entrance vestibule was open to corridor and not enclosed with corridor wall, nor was the space protected with a smoke detector to be considered as an open space permitted by NFPA 101 18.3.6.1 Exception No. 1 (c).

The above deficiency was acknowledged by the facility services director, and the chief operations officer at the time of discovery, and confirmed with the facility services director, the chief operations officer, and Staff HH (chief executive officer) at the time of exit conference on 3/7/2012 at 4 pm.

Based on observation and staff interview, the facility failed (i) to close the gap at meeting edge of two sets of corridor doors in accordance with NFPA 101 18.3.6.3.1; and (ii) to install positive latching hardware on two corridor doors to keep doors suitably closed and prevent smoke entry into or out of the spaces in the event of fire in accordance with NFPA 101 18.3.6.3.2. The deficient practice affects 2 of 11 smoke compartments.

Findings include

During a tour of the facility with Staff D (chief operations officer), Staff MM (facility services director), and Staff PP (maintenance supervisor) between 3/05 - 3/07/12, Surveyor 12316 observed that (i) on 3/5/12 at 12:05 pm, the corridor double doors of the 1st Floor Board Room and of the adjacent space beyond the accordion type folding partition had a gap of approximately 3/16 in., which is more than minimum necessary for door operation and did not prevent the passage of smoke;
(ii) corridor double doors of the Recovery suite on the 2nd Floor did not have a positive latching hardware; and
(iii) corridor door of the Gift Shop on 1st Floor had a dead bolt instead of positive latching hardware with an obvious method of operation to keep the doors suitably closed and easily operable in accordance with NFPA 101 7.2.1.5.4.

The above deficiency was acknowledged by the facility services director, and the chief operations officer at the time of discovery, and confirmed with the facility services director, the chief operations officer, and Staff HH (chief executive officer) at the time of exit conference on 3/7/2012 at 4 pm.

Based on observation and staff interview, the facility failed to ensure safety to patients due to (i) two delayed egress locked doors causing more than one door with such a device in an egress path, and (ii) three locked doors in the means of egress corridors that caused obstruction to getting access to exits. This affected 3 of 11 smoke compartments in the facility.

Findings Include


During a tour of the facility with Staff D (chief operations officer), Staff MM (facility services director), and Staff PP (maintenance supervisor) between 3/05 - 3/07/12, Surveyor 12316 observed that cross-corridor doors had either delayed egress locking arrangements, or locking arrangements requiring card to access the doors in the following locations:

1. On 3/05/12 at 4:30 pm, two smoke doors (right leaf of each set of cross-corridor smoke doors) in both north and south corridors leading to the Obstetrics (OB) Unit on the 3rd Floor had delayed egress locking arrangements in addition to the delayed egress lock on the Stairwell exit out of the OB unit. The installation of such special locking arrangements on the north leaf of each set of smoke doors in the means of egress resulted in more than one delayed egress device in egress paths, which is not permitted by NFPA 101 18.2.2.2.4, and did not provide access to exits readily in accordance with NFPA 101 18.2.1 and 7.2.1.5.1.
2. On 3/06/12 at 2:02 pm, the south leaf of cross corridor doors -Door 2274- in the Emergency Department was locked preventing access to exits;

3. On 3/06/12 at 2:02 pm, the west leaf of cross-corridor smoke doors -Door 2340- adjacent to the Imaging Staff Lounge had a locking arrangement that required a card to access the door. When interviewed on 3/06/12 at 2:05 pm, Staff HH stated that the door was locked during night. Card access arrangement to open the door in the means of egress does not meet the readily accessible and obvious method of operation requirements of NFPA 101 18.2.2.2.4, 7.2.1.5.1, 7.2.1.5.4;

4. While on a tour of the emergency department (ED) with Staff HH on 3/07/12 at 4:55 pm to determine if an exit sign was located above the cross-corridor doors in the Corridor 2274 of ED, Surveyor 12316 observed a locking arrangement on top of the door -west leaf of cross-corridor double doors- adjacent to the Electrical Closet in the ED. When interviewed, Staff HH stated that the door was locked during night and was set up to release upon activation of the building fire alarm system. Such a locking arrangement in the door that is located in a means of egress corridor does not meet the readily accessible and obvious method of operation requirements of NFPA 101 18.2.2.2.4, 7.2.1.5.1, 7.2.1.5.4.

Items 1, 2 and 3 of the above deficiency was acknowledged by the facility services director, and the chief operations officer at the time of discovery, and confirmed with the facility services director, the chief operations officer, and Staff HH (chief executive officer) at the time of exit conference on 3/7/2012 at 3:45 pm.

Item 4 of the above deficiency was acknowledged by the facility services director at the time of discovery.

Based on observation and interview, the facility failed to provide complete smoke detection coverage in the Cafeteria space that is open to corridor. This deficient practice affected 1 of 11 smoke compartments.

Findings include

During a tour of the facility with Staff D (chief operations officer), and Staff MM (facility services director) on 3/07/12, Surveyor 12316 observed at 9:27 am that a complete coverage of the Cafeteria space by smoke detectors was not provided due to two areas in that space being more than 21 ft from the nearest ceiling spot-type smoke detectors. Any corner space cannot be more than 21 ft (0.7s), where s is the manufacturer recommended spacing between smoke detectors in accordance with NFPA 72 2-3.4.5.1.2.

The above deficiency was acknowledged by the facility services director, and the chief operations officer at the time of discovery, and confirmed with the facility services director, the chief operations officer, and Staff HH (chief executive officer) at the time of exit conference on 3/7/2012 at 4 pm.

Based on observation and interview, the facility failed to install sprinkler heads of proper temperature rating in two locations in accordance with NFPA 13 5-3.1.4.1. This deficient practice affected 2 of 11 smoke compartments.


Findings include

During a tour of the facility with Staff D (chief operations officer), and Staff MM (facility services director) between 3/5- 3/7/12, Surveyor 12316 observed that (i) on 3/6/12 at 9:38 am, sprinkler heads in the Central Sterilizing/Processing Room adjacent to the surgery suite on the 2nd Floor were of intermediate temperature rating instead of ordinary-temperature rating (135 F - 170); and (ii) on 3/7/12 at 8:40 am, sprinkler heads in the Kitchen were of intermediate temperature rating and not ordinary-temperature rated. The Central Processing Room and the Kitchen are not considered hazardous areas, and require ordinary-temperature rated sprinklers in accordance with NFPA 13 5-3.1.4.1.

The above deficiency was acknowledged by the chief operations officer, and facility services director at the time of discovery, and confirmed with the facility services director, the chief operations officer, and Staff HH (chief executive officer) at the time of exit conference on 3/7/2012 at 4 pm.

Based on observation and interview, the facility failed to (i) identify the electrical receptacles supplied by the critical branch of the essential power system as to the panelboard and circuit number the power is supplied from in accordance with NFPA 99 (1999) 3-4.2.2.4(b)2, NFPA 70 (1999) 517-19(a); and (ii) supply electrical power to critical care areas by one or more branch circuits of normal power system in accordance with NFPA 99 3-3.2.1.2(a)1, NFPA 70 517-19(a). This deficient practice affected all operation rooms.

Findings include

During a tour of the facility with Staff D (chief operations officer), Staff MM (facility services director), and Staff PP (maintenance supervisor) between 3/05 - 3/07/12, Surveyor 12316 observed that (i) on 3/5/2012 at 4:09 pm, critical branch of the essential power system supplied electrical wall outlets in the six intensive care unit (ICU) patient rooms on the 3rd Floor were not identified as to which panelboard and circuit number the essential power was supplied from;
(ii) On 3/6/2012 at 9:10 am, the Operation Room (OR) #4 did not have at least one branch circuit supplied by normal power distribution system; ORs #1, 2, 3 and 5 could not be verified for normal power electrical outlets due to ongoing surgery procedure at the time of survey; and OR #6 that was used as a clean supply storage did not have the normal power outlets either; and
(iii) On 3/6/2012 at 1:16 pm, emergency power critical branch supplied electrical outlets on the headwalls of Trauma Rooms A and B in the 1st Floor emergency department were not identified as to which panelboard and circuit number the essential power was supplied from.

The above deficiency was acknowledged by the facility services director, and the chief operations officer at the time of discovery, and confirmed with the facility services director, the chief operations officer, and Staff HH (chief executive officer) at the time of exit conference on 3/7/2012 at 4 pm.