HospitalInspections.org

.
Based on document review of the fire alarm and smoke detectors, it was revealed that the facility failed to maintain the fire alarm and smoke detection system in fully operating condition.

Review of the Fire Alarm Initiating Devices: 2nd semi annual test of 2010 revealed the following:

1- The manual pull station of the fire alarm on the subbasement next to Stair 2 was not functioning.

2- The Acme gangs near Stairs 1 and 2, one (1) bell was not functioning.

3- The Acme gangs on the corridor of the 4th Floor near Stairs 1 and 2 were not functioning.

4- The smoke detector at Room A3-504 failed the test. No documented evidence of correcting this problem until the time of the survey.

5- The smoke detector at Room A3-541 failed the test. No documented evidence of correcting this problem until the time of the survey.

6- The smoke detector at Room A3-503 failed the test. No documented evidence of correcting this problem until the time of the survey.

7- The smoke detector at IFO Room A2-531 failed the test. No documented evidence of correcting this problem until the time of the survey.

8- The smoke detector at IFO Room A2-646 was missing. No documented evidence of correcting this problem until the time of the survey.

9- The duct detector 19-020 at EF-126 was not working.

10- The smoke detector at Stair F - Zone 14/16 was not responding.

11- The smoke detector at elevator Lobby #15/16 was missing device.
.

.
Based on document review of the fire alarm and smoke detectors, it was revealed that the facility failed to maintain the smoke detection system in fully operating condition.

Review of the Fire Alarm Initiating Devices: 2nd semi annual test of 2010 revealed the following:

1- The smoke detector at Room A3-504 failed the test. No documented evidence of correcting this problem until the time of the survey.

2- The smoke detector at Room A3-541 failed the test. No documented evidence of correcting this problem until the time of the survey.

3- The smoke detector at Room A3-503 failed the test. No documented evidence of correcting this problem until the time of the survey.

4- The smoke detector at IFO Room A2-531 failed the test. No documented evidence of correcting this problem until the time of the survey.

5- The smoke detector at IFO Room A2-646 was missing. No documented evidence of correcting this problem until the time of the survey.

6- The duct detector 19-020 at EF-126 was not working.

7- The smoke detector at Stair F - Zone 14/16 was not responding.

8- The smoke detector at elevator Lobby #15/16 was missing device.
.

Review of the sprinkler system and fire alarm testing and preventive maintenance records showed that the facility failed to ensure that the sprinkler system and fire alarm system are maintained in fully operational condition.

Findings included but were not limited to:

Sprinkler System - Main Drain Test on 3/4/2010:

1- The OS&Y valves were reported to be corroded with no evidence of follow-up or correcting the problem.

2- Ten (10) tamper valves were reported to be inoperable with no evidence of follow-up or correcting the problem.

3- The water flow switches did not signal.

4- The Subbasement 303C Alarm check and gate valve 35 linen Chute needed to be replaced with no evidence of follow-up or correcting the problem.

5- The sprinkler head in base Trash EM needed to be replaced with no evidence of follow-up or correcting the problem.

6- The distribution piping changes due to internal construction modification must be examined to ensure proper coverage is provided with no evidence of follow-up or correcting the problem.


Sprinkler System - Connection S: 9/24/2010:

1- The water Motor gang does not operate at Clarkson Ave.

2- Ten (10) tamper switches do not signal to fire panels.

3- Eight (8) OS&Y valves are corroded and require service.

4- Three (3) water flow switches do not signal to the fire alarm panel.

5- The distribution piping changes due to internal construction modification must be examined to ensure proper coverage is provided with no evidence of follow-up or correcting the problem.


Sprinkler System - Connection S: 11/23/2010:

1- The water motor gang did not operate at Clarkson Ave.

2- The tamper switches did not signal to the fire alarm panel.

3- Eight (8) OS&Y valves are corroded and required service.

4- The distribution piping changes due to internal construction modification must be examined to ensure proper coverage is provided with no evidence of follow-up or correcting the problem.

5- Valve #11 of water flow switch needs to be replaced with no evidence of follow-up or correcting the problem.
.

.
Based on observation and staff interview, the facility failed to maintain the means of egress free of obstructions or impediments to full instant use in the case of fire or other emergency.

Findings include:

During a tour of the Emergency Department on 6/27/11, the corridors of the Emergency Department were observed to be obstructed by various items as follows:

1- The Ambulance corridor between the Fast Track, Pediatric ED and Adult ED was observed to be partly blocked at both sides by two (2) patient stretchers, an Ultrasonic Machine, two (2) Cardiac Monitors and a BIPAP Machine (Ventilator Support System).

2- The corridors of the Adult ED were blocked by eight (8) patient beds or stretchers with patients were receiving their treatment in the corridor of the ED.

.
Based on document review of the fire alarm and smoke detectors, it was revealed that the facility failed to maintain the fire alarm and smoke detection system in fully operating condition.

Review of the Fire Alarm Initiating Devices: 2nd semi annual test of 2010 revealed the following:

1- The manual pull station of the fire alarm on the subbasement next to Stair 2 was not functioning.

2- The Acme gangs near Stairs 1 and 2, one (1) bell was not functioning.

3- The Acme gangs on the corridor of the 4th Floor near Stairs 1 and 2 were not functioning.

4- The smoke detector at Room A3-504 failed the test. No documented evidence of correcting this problem until the time of the survey.

5- The smoke detector at Room A3-541 failed the test. No documented evidence of correcting this problem until the time of the survey.

6- The smoke detector at Room A3-503 failed the test. No documented evidence of correcting this problem until the time of the survey.

7- The smoke detector at IFO Room A2-531 failed the test. No documented evidence of correcting this problem until the time of the survey.

8- The smoke detector at IFO Room A2-646 was missing. No documented evidence of correcting this problem until the time of the survey.

9- The duct detector 19-020 at EF-126 was not working.

10- The smoke detector at Stair F - Zone 14/16 was not responding.

11- The smoke detector at elevator Lobby #15/16 was missing device.
.

.
Based on document review of the fire alarm and smoke detectors, it was revealed that the facility failed to maintain the smoke detection system in fully operating condition.

Review of the Fire Alarm Initiating Devices: 2nd semi annual test of 2010 revealed the following:

1- The smoke detector at Room A3-504 failed the test. No documented evidence of correcting this problem until the time of the survey.

2- The smoke detector at Room A3-541 failed the test. No documented evidence of correcting this problem until the time of the survey.

3- The smoke detector at Room A3-503 failed the test. No documented evidence of correcting this problem until the time of the survey.

4- The smoke detector at IFO Room A2-531 failed the test. No documented evidence of correcting this problem until the time of the survey.

5- The smoke detector at IFO Room A2-646 was missing. No documented evidence of correcting this problem until the time of the survey.

6- The duct detector 19-020 at EF-126 was not working.

7- The smoke detector at Stair F - Zone 14/16 was not responding.

8- The smoke detector at elevator Lobby #15/16 was missing device.
.

Review of the sprinkler system and fire alarm testing and preventive maintenance records showed that the facility failed to ensure that the sprinkler system and fire alarm system are maintained in fully operational condition.

Findings included but were not limited to:

Sprinkler System - Main Drain Test on 3/4/2010:

1- The OS&Y valves were reported to be corroded with no evidence of follow-up or correcting the problem.

2- Ten (10) tamper valves were reported to be inoperable with no evidence of follow-up or correcting the problem.

3- The water flow switches did not signal.

4- The Subbasement 303C Alarm check and gate valve 35 linen Chute needed to be replaced with no evidence of follow-up or correcting the problem.

5- The sprinkler head in base Trash EM needed to be replaced with no evidence of follow-up or correcting the problem.

6- The distribution piping changes due to internal construction modification must be examined to ensure proper coverage is provided with no evidence of follow-up or correcting the problem.


Sprinkler System - Connection S: 9/24/2010:

1- The water Motor gang does not operate at Clarkson Ave.

2- Ten (10) tamper switches do not signal to fire panels.

3- Eight (8) OS&Y valves are corroded and require service.

4- Three (3) water flow switches do not signal to the fire alarm panel.

5- The distribution piping changes due to internal construction modification must be examined to ensure proper coverage is provided with no evidence of follow-up or correcting the problem.


Sprinkler System - Connection S: 11/23/2010:

1- The water motor gang did not operate at Clarkson Ave.

2- The tamper switches did not signal to the fire alarm panel.

3- Eight (8) OS&Y valves are corroded and required service.

4- The distribution piping changes due to internal construction modification must be examined to ensure proper coverage is provided with no evidence of follow-up or correcting the problem.

5- Valve #11 of water flow switch needs to be replaced with no evidence of follow-up or correcting the problem.
.

.
Based on observation and staff interview, the facility failed to maintain the means of egress free of obstructions or impediments to full instant use in the case of fire or other emergency.

Findings include:

During a tour of the Emergency Department on 6/27/11, the corridors of the Emergency Department were observed to be obstructed by various items as follows:

1- The Ambulance corridor between the Fast Track, Pediatric ED and Adult ED was observed to be partly blocked at both sides by two (2) patient stretchers, an Ultrasonic Machine, two (2) Cardiac Monitors and a BIPAP Machine (Ventilator Support System).

2- The corridors of the Adult ED were blocked by eight (8) patient beds or stretchers with patients were receiving their treatment in the corridor of the ED.