HospitalInspections.org

Based on observation during tours of the hospital, the hospital did not ensure that the access to exits were marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. 7.10.1.4


Finding was:

During a tour of Maternal Fetal Evaluation unit on 11/13/2015, there were no readily visible signs to direct the patients and the staff to the exit of the unit as per NFPA 101 edition 2000 - 7.10.1.4.
This finding was verified at the time of observation by the Director of Facilities and Senior Associate Director for Capital Design.

Based on observation, the facility failed to demonstrate that the doors in a smoke barrier had the necessary fire rating. This deficiency could affect staff, patients, and visitors in the event of a fire emergency.

The findings are:

1) During the building tour of Tuesday 11/10/15, it was noted that the door in the smoke barrier between business and health care occupancies on the 8th floor had a rating label that was painted over.

This finding was verified at the time of observation by the Interim Director of Engineering and the Associate Fire Safety Director.

Based on observation, the facility failed to demonstrate the fire rated construction around hazardous areas in the hospital basement was maintained. This deficiency could affect staff and visitors to this area in the event of a fire emergency.

The findings include:

1) During the building tour of Tuesday 11/10/15 between 10 am and 11 am, it was noted that the rating labels on the doors to the housekeeping storage room, the electrical shop, paint shop, and carpentry shop in the basement were painted over, obscuring the door rating information. The life safety drawing shows these areas to be surrounded by a 2 hour fire rated wall, and as such the facility must demonstrate that the doors to these areas have a 90 minute rating.

These findings were verified at the time of observation by the Interim Director of Engineering and the Associate Director of Fire Safety.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system in reliable operating condition. This deficiency could affect the patients, visitors, and staff should the sprinkler system fail to function in the event of a fire emergency.

The findings include:

1) During the building tour on Monday 11/9/15 at approximately 10:30 am, supplies in the Emergency Department (ED) Supply Room were noted to be stored less than 18 inches from a sprinkler head.
2) At approximately 10:35 am on 11/9/15 in the soiled holding room (room # G1-041) in the ED area A, a sprinkler head was noted to be installed less than 12 inches from a ceiling air supply diffuser. This did not meet the requirement of NFPA 13 section 5.1.1 and Table 5-3.1.4.2.
3) On Tuesday 11/10/15 at approximately 9:15 am, a sprinkler cap and adjacent ceiling tiles located in the staff locker room behind the basement pharmacy were noted to have rusty water stains which may indicate leakage in the sprinkler piping.
4) On Thursday 11/12/15 at approximately 10:45 am, a sprinkler head in the biomed equipment repair room of the Hemodialysis Unit was noted to be missing a sprinkler cap.
5) At approximately 11:50 am on 11/12/15, spare sidewall sprinklers and the appropriate sprinkler wrench were noted to be missing from the engineering office where such supplies are kept. This deficiency was corrected at the time of the survey, however, an inventory tracking system for spare sprinkler heads should be maintained to ensure availability of this equipment.

These findings were verified at the time of observation by the Interim Director of Engineering and the Associate Director of Fire Safety.

Based on observation, the facility failed to maintain the integrity of interior partitions in a building of Construction Type II. This deficiency could affect staff, patients, and visitors to the hospital in the event of a fire emergency.

The findings are:

1) During the building tour on Monday 11/9/15 at approximately 11:00 am, fire proofing spray was noted missing from two areas on a steel beam in the former blood draw room (currently used as stretcher storage) on the first floor.
2) On Tuesday 11/10/15 between 9:45 am and 11:15 am, fire spray was noted missing from steel beams in the following locations in the basement:
- The carpentry shop (room C14).
- The pharmacy in the back of the robotics room.
- The syringe storage room in the central supply storage area.

These findings were verified at the time of observation by the Interim Director of Engineering and the Associate Fire Safety Dir.

Based on staff interview and document review, it was determined that the hospital's emergency generators are not in compliance with the requirements of NFPA 99. The Hospital's Essential Electrical System is not Type I EES because it is not divided into the critical branch, life safety branch, and the equipment branch in accordance with NFPA 99 - 3.4.2.2.2.
The hospital performs general anesthesia and has patients who use Life Support Systems (Ventilators) and is required to comply with the provision of Type 1 EES system (Essential Electrical System).

Findings include:

In an interview with the Director of Facilities on 11/16/15 and review of the directions on the panels of the Essential Electrical System (EES), it was determined that the wiring configuration of the Essential Electrical System in the facility does not conform with Type I EES and therefore, the EES system in the hospital does not comply with 1999 NFPA 99 3-4.2.2.1.
The specific issue involved was the separation of the generator branches into a Life Safety branch, Critical, and Equipment branches as per the requirement of NFPA 99. The Director of Facilities indicated that the hospital as a whole does not have a code compliant EES Type 1 as per NFPA 99 requirement. The Hospital performs general anesthesia and operates a ventilator dependent unit, and as such, requires a Type I EES.

Review of the documentation and drawings provided by the hospital that address this deficiency also revealed that items required to be served by the Equipment Branch of the EES system were not independent or separate from items required to be served by the Life Safety Branch of EES system, and/or from items required to be served the Critical Branch of the EES system.

During an interview with the hospital leaders (Director of Engineering, Director of Facilities, Senior Associate Director for Capital Design, Assistant VP of Facilities of NYC-HHC and the Regional Director-Jonson Control) on the morning of 11/16/2015, they acknowledged and confirmed the findings and they mentioned that they are fully aware of the deficiency and that they are working on a plan to correct it and to bring the EES type I system into compliance.


1999 NFPA 99 3-4.2.1.4, 3-4.2.2, NFPA 70: Article 517 and Article 70

Based on observation during tours of the hospital, the hospital did not ensure that the access to exits were marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. 7.10.1.4


Finding was:

During a tour of Maternal Fetal Evaluation unit on 11/13/2015, there were no readily visible signs to direct the patients and the staff to the exit of the unit as per NFPA 101 edition 2000 - 7.10.1.4.
This finding was verified at the time of observation by the Director of Facilities and Senior Associate Director for Capital Design.

Based on observation, the facility failed to demonstrate that the doors in a smoke barrier had the necessary fire rating. This deficiency could affect staff, patients, and visitors in the event of a fire emergency.

The findings are:

1) During the building tour of Tuesday 11/10/15, it was noted that the door in the smoke barrier between business and health care occupancies on the 8th floor had a rating label that was painted over.

This finding was verified at the time of observation by the Interim Director of Engineering and the Associate Fire Safety Director.

Based on observation, the facility failed to demonstrate the fire rated construction around hazardous areas in the hospital basement was maintained. This deficiency could affect staff and visitors to this area in the event of a fire emergency.

The findings include:

1) During the building tour of Tuesday 11/10/15 between 10 am and 11 am, it was noted that the rating labels on the doors to the housekeeping storage room, the electrical shop, paint shop, and carpentry shop in the basement were painted over, obscuring the door rating information. The life safety drawing shows these areas to be surrounded by a 2 hour fire rated wall, and as such the facility must demonstrate that the doors to these areas have a 90 minute rating.

These findings were verified at the time of observation by the Interim Director of Engineering and the Associate Director of Fire Safety.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system in reliable operating condition. This deficiency could affect the patients, visitors, and staff should the sprinkler system fail to function in the event of a fire emergency.

The findings include:

1) During the building tour on Monday 11/9/15 at approximately 10:30 am, supplies in the Emergency Department (ED) Supply Room were noted to be stored less than 18 inches from a sprinkler head.
2) At approximately 10:35 am on 11/9/15 in the soiled holding room (room # G1-041) in the ED area A, a sprinkler head was noted to be installed less than 12 inches from a ceiling air supply diffuser. This did not meet the requirement of NFPA 13 section 5.1.1 and Table 5-3.1.4.2.
3) On Tuesday 11/10/15 at approximately 9:15 am, a sprinkler cap and adjacent ceiling tiles located in the staff locker room behind the basement pharmacy were noted to have rusty water stains which may indicate leakage in the sprinkler piping.
4) On Thursday 11/12/15 at approximately 10:45 am, a sprinkler head in the biomed equipment repair room of the Hemodialysis Unit was noted to be missing a sprinkler cap.
5) At approximately 11:50 am on 11/12/15, spare sidewall sprinklers and the appropriate sprinkler wrench were noted to be missing from the engineering office where such supplies are kept. This deficiency was corrected at the time of the survey, however, an inventory tracking system for spare sprinkler heads should be maintained to ensure availability of this equipment.

These findings were verified at the time of observation by the Interim Director of Engineering and the Associate Director of Fire Safety.

Based on observation, the facility failed to maintain the integrity of interior partitions in a building of Construction Type II. This deficiency could affect staff, patients, and visitors to the hospital in the event of a fire emergency.

The findings are:

1) During the building tour on Monday 11/9/15 at approximately 11:00 am, fire proofing spray was noted missing from two areas on a steel beam in the former blood draw room (currently used as stretcher storage) on the first floor.
2) On Tuesday 11/10/15 between 9:45 am and 11:15 am, fire spray was noted missing from steel beams in the following locations in the basement:
- The carpentry shop (room C14).
- The pharmacy in the back of the robotics room.
- The syringe storage room in the central supply storage area.

These findings were verified at the time of observation by the Interim Director of Engineering and the Associate Fire Safety Dir.

Based on staff interview and document review, it was determined that the hospital's emergency generators are not in compliance with the requirements of NFPA 99. The Hospital's Essential Electrical System is not Type I EES because it is not divided into the critical branch, life safety branch, and the equipment branch in accordance with NFPA 99 - 3.4.2.2.2.
The hospital performs general anesthesia and has patients who use Life Support Systems (Ventilators) and is required to comply with the provision of Type 1 EES system (Essential Electrical System).

Findings include:

In an interview with the Director of Facilities on 11/16/15 and review of the directions on the panels of the Essential Electrical System (EES), it was determined that the wiring configuration of the Essential Electrical System in the facility does not conform with Type I EES and therefore, the EES system in the hospital does not comply with 1999 NFPA 99 3-4.2.2.1.
The specific issue involved was the separation of the generator branches into a Life Safety branch, Critical, and Equipment branches as per the requirement of NFPA 99. The Director of Facilities indicated that the hospital as a whole does not have a code compliant EES Type 1 as per NFPA 99 requirement. The Hospital performs general anesthesia and operates a ventilator dependent unit, and as such, requires a Type I EES.

Review of the documentation and drawings provided by the hospital that address this deficiency also revealed that items required to be served by the Equipment Branch of the EES system were not independent or separate from items required to be served by the Life Safety Branch of EES system, and/or from items required to be served the Critical Branch of the EES system.

During an interview with the hospital leaders (Director of Engineering, Director of Facilities, Senior Associate Director for Capital Design, Assistant VP of Facilities of NYC-HHC and the Regional Director-Jonson Control) on the morning of 11/16/2015, they acknowledged and confirmed the findings and they mentioned that they are fully aware of the deficiency and that they are working on a plan to correct it and to bring the EES type I system into compliance.


1999 NFPA 99 3-4.2.1.4, 3-4.2.2, NFPA 70: Article 517 and Article 70