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Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having all doors to the corridors ready to close with a means suitable for keeping the door closed.

The findings include:

During the initial survey on December 5, 2011 with the Vice President of Facilities and executive members of the building operations staff, it was observed between 8:30 am and 3:00 pm that the door to custodial closet #NBW52 (North Hospital Building) had the strike plate taped over to prevent the door from latching properly.

A strike plate is a metal plate affixed to a door jamb with a hole or holes for the bolt of the door. When the door is closed, the bolt extends into the hole in the strike plate, and holds the door closed. The strike plate protects the jamb against friction from the bolt, and increases security in the case of a jamb made of a softer material (such as wood) than the strike plate.

This could allow smoke or fire to pass between the custodial closet and the patient corridor. The tape was removed during the survey and staff members were instructed as to proper procedures for doors.

Based on observation of the physical environment, it was determined that the facility staff failed to provide base level protection by not ensuring that smoke barrier doors function properly.

The findings include:

During the initial survey on December 5, 6, and 7, 2011 with the Vice President of Facilities and executive members of the building operations staff, it was observed between 8:30 am and 3:00 pm each day that:

1.) Several corridor smoke barrier doors were blocked from closing by medication and/or computer carts or trash can carts in several locations including, but not limited to, 5th floor Gudelsky Building, 6th floor Weinberg Building, and 7th floor Weinberg Building;

2.) Smoke barrier doors in several locations closed too slowly or not at all, including: Weinberg Building to IPHB service corridor; Weinberg 7th floor from atrium to patient corridor.

Smoke barrier doors, walls, and partitions are designed to insulate means of egress from other areas of a building and to resist the passage of smoke in the event of an emergency and failure to do so could impact patients and staff.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining self closing doors from hazardous areas to exit corridors.

The findings include:

During the initial survey on December 5, 2011 with the Vice President of Facilities and executive members of the building operations staff, it was observed between 8:30 am and 3:00 pm that one door to the housekeeping central supply #NGE10A (North Hospital Building) was held open with a non-approved hold open device - a wood chock. This was removed during the survey and the door was closed. Later during the three-day survey, the door was again found to be propped open with the same device. It was removed a 2nd time. NOTE: A second door from this area to the exit corridor was properly held open with a magnetic lock connected to the alarm system.

All doors to the exit corridors from hazardous areas must be self-closing in the event of an emergency and must not be held open unless by an approved device that is connected to the alarm system.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining medical gas storage areas in accordance with NFPA 99.

The findings include:

During the initial survey on December 5, 6, and 7, 2011 with the Vice President of Facilities and executive members of the building operations staff, it was observed between 8:30 am and 3:00 pm each day that:

1.) Oxygen storage locations on the floors throughout the hospital buildings had no signs indicating: "Oxygen Storage." This included, but was not limited to, oxygen storage areas in linen rooms, nurse's stations, general storage areas, etc.

A precautionary sign, readable from a distance of 1.5 m (5') shall be displayed on each door or gate of the storage room or enclosure: CAUTION: OXYGEN STORAGE or CAUTION: OXIDIZING GAS(ES) STORED WITHIN. An Oxygen placard is also acceptable. In large central storage areas where oxygen and assorted medical gases are stored, appropriate signage is also required. This should also include areas where empty tanks are stored prior to pickup.

This could result in staff, visitors, first responders, or firefighters not knowing where oxygen was stored and could impact patients and staff in the event of an emergency or fire.

2.) Several smaller sized oxygen tanks (Jumbo D) in the empty tank storage room (1 tank) and in the central medical gas storage room (6 tanks) were not secured properly to prevent falls and/or physical damage. These were corrected during the survey.

Unsecured oxygen tanks could lead to damage or personal injury in the event of a fall.

Based on observation of the physical environment and interviews with staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the Type I Essential Electrical System powered by emergency generators in accordance with NFPA 99.

The findings include:

During the initial survey on December 5, 6, and 7, 2011 with the Vice President of Facilities and executive members of the building operations staff, it was observed between 8:30 am and 3:00 pm that there were four panels for the emergency generators in the small electrical panel room behind the security desk in the main lobby. This panel room is not staffed at all times but there is 24 hour staffing in the main emergency operations center. However, staff at the security desk and in the operations center were not familiar with the generator annunciator panels. They also were not familiar with which procedures to follow in the event of a generator failure or early warning of trouble.

This could result in a malfunction or non-operation of the generator(s) and after-hours staff having no knowledge of the problem.

Staff members involved with security and emergency operations monitoring need to be trained and protocols implemented to manage generator monitoring through the annunciator panels on a 24 hour basis.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not having all doors to the corridors ready to close with a means suitable for keeping the door closed.

The findings include:

During the initial survey on December 5, 2011 with the Vice President of Facilities and executive members of the building operations staff, it was observed between 8:30 am and 3:00 pm that the door to custodial closet #NBW52 (North Hospital Building) had the strike plate taped over to prevent the door from latching properly.

A strike plate is a metal plate affixed to a door jamb with a hole or holes for the bolt of the door. When the door is closed, the bolt extends into the hole in the strike plate, and holds the door closed. The strike plate protects the jamb against friction from the bolt, and increases security in the case of a jamb made of a softer material (such as wood) than the strike plate.

This could allow smoke or fire to pass between the custodial closet and the patient corridor. The tape was removed during the survey and staff members were instructed as to proper procedures for doors.

Based on observation of the physical environment, it was determined that the facility staff failed to provide base level protection by not ensuring that smoke barrier doors function properly.

The findings include:

During the initial survey on December 5, 6, and 7, 2011 with the Vice President of Facilities and executive members of the building operations staff, it was observed between 8:30 am and 3:00 pm each day that:

1.) Several corridor smoke barrier doors were blocked from closing by medication and/or computer carts or trash can carts in several locations including, but not limited to, 5th floor Gudelsky Building, 6th floor Weinberg Building, and 7th floor Weinberg Building;

2.) Smoke barrier doors in several locations closed too slowly or not at all, including: Weinberg Building to IPHB service corridor; Weinberg 7th floor from atrium to patient corridor.

Smoke barrier doors, walls, and partitions are designed to insulate means of egress from other areas of a building and to resist the passage of smoke in the event of an emergency and failure to do so could impact patients and staff.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining self closing doors from hazardous areas to exit corridors.

The findings include:

During the initial survey on December 5, 2011 with the Vice President of Facilities and executive members of the building operations staff, it was observed between 8:30 am and 3:00 pm that one door to the housekeeping central supply #NGE10A (North Hospital Building) was held open with a non-approved hold open device - a wood chock. This was removed during the survey and the door was closed. Later during the three-day survey, the door was again found to be propped open with the same device. It was removed a 2nd time. NOTE: A second door from this area to the exit corridor was properly held open with a magnetic lock connected to the alarm system.

All doors to the exit corridors from hazardous areas must be self-closing in the event of an emergency and must not be held open unless by an approved device that is connected to the alarm system.

Based on observation of the physical environment, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining medical gas storage areas in accordance with NFPA 99.

The findings include:

During the initial survey on December 5, 6, and 7, 2011 with the Vice President of Facilities and executive members of the building operations staff, it was observed between 8:30 am and 3:00 pm each day that:

1.) Oxygen storage locations on the floors throughout the hospital buildings had no signs indicating: "Oxygen Storage." This included, but was not limited to, oxygen storage areas in linen rooms, nurse's stations, general storage areas, etc.

A precautionary sign, readable from a distance of 1.5 m (5') shall be displayed on each door or gate of the storage room or enclosure: CAUTION: OXYGEN STORAGE or CAUTION: OXIDIZING GAS(ES) STORED WITHIN. An Oxygen placard is also acceptable. In large central storage areas where oxygen and assorted medical gases are stored, appropriate signage is also required. This should also include areas where empty tanks are stored prior to pickup.

This could result in staff, visitors, first responders, or firefighters not knowing where oxygen was stored and could impact patients and staff in the event of an emergency or fire.

2.) Several smaller sized oxygen tanks (Jumbo D) in the empty tank storage room (1 tank) and in the central medical gas storage room (6 tanks) were not secured properly to prevent falls and/or physical damage. These were corrected during the survey.

Unsecured oxygen tanks could lead to damage or personal injury in the event of a fall.

Based on observation of the physical environment and interviews with staff, it was determined that the facility staff failed to provide a safe and hazard free environment by not maintaining the Type I Essential Electrical System powered by emergency generators in accordance with NFPA 99.

The findings include:

During the initial survey on December 5, 6, and 7, 2011 with the Vice President of Facilities and executive members of the building operations staff, it was observed between 8:30 am and 3:00 pm that there were four panels for the emergency generators in the small electrical panel room behind the security desk in the main lobby. This panel room is not staffed at all times but there is 24 hour staffing in the main emergency operations center. However, staff at the security desk and in the operations center were not familiar with the generator annunciator panels. They also were not familiar with which procedures to follow in the event of a generator failure or early warning of trouble.

This could result in a malfunction or non-operation of the generator(s) and after-hours staff having no knowledge of the problem.

Staff members involved with security and emergency operations monitoring need to be trained and protocols implemented to manage generator monitoring through the annunciator panels on a 24 hour basis.