The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
| ROSELAND COMMUNITY HOSPITAL | 45 W 111TH STREET CHICAGO, IL 60628 | Oct. 4, 2017 |
| VIOLATION: Multiple Occupancies | Tag No: K0131 | |
| Based on observation, the facility failed to maintain adequate fire rated occupancy separations. This deficient practice could affect patients, staff and visitors if a fire were permitted to spread without proper fire separation. Findings include: On October 4, 2017 at 9:20 AM, while accompanied by the CE on the 3rd floor, the Life Safety Drawings indicated a 2-hour rated separation wall between the leased space "Aunt Martha Suite" and the remainder of the floor. The separation wall contained five unsealed conduit penetrations which does not meet with 19.1.2.3 or 8.3.1. |
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| VIOLATION: ALCOHOL BASED HAND RUBS | Tag No: K0211 | |
| Based on observation, means of egress doors are not maintained free of impediments to access areas of refuge or exits from the building. Failure to provide an unobstructed means of egress can compromise occupants' ability to promptly reach an area of safety. Findings include: A. On October 4, 2017 at 9:45am while in the company of the SDSS it was observed that the basement Dietary Store Room door was equipped with a hasp & padlock in noncompliance with 7.2.1.5.3. B. On October 4, 2017 while in the company of the SDSS it was observed that dead bolt locks in addition to latching hardware are installed on doors serving more than three occupants which does not comply with 7.2.1.5.10.6. Locations observed include: 1. At 10:15am at the 1st floor Billing Office. 2. At 10:20am at the 1st floor Kitchen south corridor door. 3. At 1:00pm at the 1st floor Pharmacy two corridor doors. C. On October 4, 2017 at 10:15am while in the company of the SDSS it was observed that the S-2 air handler room (in the Kitchen) was provided with operating hardware mounted above the maximum 48" height permitted by 7.2.1.5.10.1(2). |
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| VIOLATION: Stairways and Smokeproof Enclosures | Tag No: K0225 | |
| Based on observation, not all portions of the building's exit enclosures are maintained as required. This deficient practice could affect any patients, staff, and visitors in the building required to use the exit to evacuate the building during an emergency. Findings include: On October 4, 2017 at 11:45am, while in the company of the SDSS, it was observed that the discharge area of the south center stair extending from the 5th floor, determined to be an unsprinklered exit passageway, was being used as a locker room space where metal lockers and a chair were stationed in noncompliance with 7.1.3.2.3. The ramp at this location, constructed over the original stair risers and used for transport from the morgue to grade level, lacked at least one handrail to comply with 7.2.2.4.1.6. |
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| VIOLATION: Horizontal Exits | Tag No: K0226 | |
| Based on observations during the survey walk-through and review of the facility provided information and floor plans, fire barriers do not comply with requirements. This deficiency could affect all patients, staff and visitors if fire/smoke was permitted to extend beyond the barrier. Findings include: On October 4, 2017 at 11:30am it was observed while accompanied by the SDSS & AE, that the designated three-hour fire/smoke rated separation within the 1st floor Radiology suite had unprotected penetrations of wiring and cables not sealed to resist the passage of fire/smoke in accordance with 8.3.5.1. |
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| VIOLATION: Dead-End Corridors and Common Path of Travel | Tag No: K0251 | |
| Based on observation, the facility failed to provide adequate exiting arrangements. This condition could affect patients, staff and visitors if the means of egress is compromised due to the lack of directional signage in case of an emergency. Findings include: On October 4, 2017 at 9:25 AM, while accompanied by the CE on the 4th floor, the corridor leading to the S4 stairway only had one exit route identified creating a dead end corridor condition. The current arrangement does not meet with 19.2.4.3 or 19.2.5.2 |
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| VIOLATION: Sprinkler System - Installation | Tag No: K0351 | |
| Based on direct observation and staff interview the facility failed to install emergency lighting within the fire pump rooms. Failure to provide illumination for these spaces could delay response and fire suppression if the pump failed. This deficient practice could affect patients, staff and visitors during a fire event. Findings are: A. On 10/4/17 at 10:50 AM accompanied by the SE it was determined through observation and staff interview that the lighting for No. 1 fire pump room was not connected to the emergency lighting system. NFPA 20, 2010, 4.12.5 B. On 10/4/17 at 10:55 AM accompanied by the SE it was determined through observation and staff interview that the lighting for No. 2 fire pump room was not connected to the emergency lighting system. NFPA 20, 2010, 4.12.5 |
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| VIOLATION: Sprinkler System - Maintenance and Testing | Tag No: K0353 | |
| Based on the document review, it was determined that the facility failed to maintain the sprinkler system as required. This deficient practice could affect patients, staff and visitors in the building if the sprinkler system failed to activate due to lack of maintenance. Findings include: On October 3, 2017 at 1:00 PM, the following test and inspection documents were reviewed and found to contain uncorrected deficiencies which does not meet with 9.7.5. 1. Sprinkler test "tamper switch report" dated 7/28/17 indicated Stair 5 Basement (L1M002) tamper OSY failed. "Valve seized" the revised report dated 10/4/17 indicated that this issue has not been resolved. 2. Sprinkler test "tamper switch report" dated 7/28/17 indicated two fire department connections outside NE that are missing caps the revised report dated 10/4/17 failed to indicate that this deficiency has been resolved. |
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| VIOLATION: Portable Fire Extinguishers | Tag No: K0355 | |
| Based on observation during the survey walk through, the facility failed to provide access and correct signage for the use of fire extinguishers in the kitchen. This deficient practice could affect patients, staff and visitors during a kitchen cooking grease fire event. The finding is: On 10/4/17 at 9:30 AM accompanied by the SE, it was observed that the installed K fire extinguisher is installed above a work counter and lacks signage for the correct sequence and use of the K fire extinguisher. NFPA 96, 2008, 10.2.2 |
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| VIOLATION: Corridors - Construction of Walls | Tag No: K0362 | |
| Based on observation, the facility failed to provide adequate protection of corridor walls. This condition could affect patients, staff and visitors if the means of egress is compromised due to the lack of protection from fire or smoke if there is a fire/smoke event. Finding includes: A. On October 4, 2017 at 9:00 AM, while accompanied by the CE on the 4th floor in the LDR unit near room 408, the Life Safety drawings indicate the corridor walls are 1 hour fire rated. Unsealed low voltage wire penetrations were observed above the original metal pan ceiling. This does not meet with 19.3.6.2 or 8.3.5 B. On October 4, 2017 at 2:00 PM, while accompanied by the CE on the 2nd floor lobby by Stair 1, the Life Safety drawings indicates the walls are 1 hour fire rated. To the left of the elevator, an unsealed 3" hole was observed. This does not meet with 19.3.6.2 or 8.3.5. |
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| VIOLATION: Electrical Systems - Essential Electric Syste | Tag No: K0915 | |
| Based on observation, the facility failed to install their electrical system as required. This deficient practice could affect patients, staff and visitors in the building because the proper branch circuits are not provided and load shedding during an emergency would be impartial or impossible. Findings include: On October 4, 2017 at 11:00 AM, while accompanied by the CE, it was observed that the general care patient rooms failed to contain designated emergency power receptacles per NFPA 99, 6.3.2.2.6.2 (a) and NFPA 70 (2011) 517.18. |
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| VIOLATION: Electrical Systems - Essential Electric Syste | Tag No: K0916 | |
| Based on observation and staff interview during the survey walk through, the facility failed to install a complete alarm monitoring system for the emergency electrical system. Failure to install and maintain these systems could result in delayed response to electrical system malfunction. This deficient practice could affect patients, staff and visitors during a utility power outage. The finding is: A. On 10/4/17 at 10:50 AM accompanied by the SE it was determined through observation and staff interview that a remote audible alarm is not provide at a work station observable by personnel for the main hospital generator located in the penthouse on the second floor roof. NFPA 99, 2012 6.4.1.1.17.1 Based on observation during the survey walk through the facility failed to provide battery warmers for the emergency generators. Failure to install and maintain these systems could result in delayed response to electrical system malfunction. This deficient practice could affect patients, staff and visitors during a utility power outage. Finding are: B. On 10/4/17 at 9:40 AM accompanied by the SE it was determined through observation that the starting batteries are not provided with heaters with auto shutoff for the emergency generator serving fire pumps 1 & 2. NFPA 110, 2010, 5.3.1 C. On 10/4/17 at 10:00 AM accompanied by the SE it was determined through observation that the starting batteries are not provided with heaters with auto shutoff for the Emergency Department emergency generator. NFPA 110, 2010, 5.3.1 |
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| VIOLATION: Protection - Other | Tag No: K0300 | |
| Based on the document review, it was determined that the facility failed to maintain the Halon system as required. This deficient practice could affect patients, staff and visitors in the building if the fire suppression system failed to activate due to lack of maintenance. Findings include: On October 3, 2017 at 1:20 PM, the following test and inspection documents were reviewed and found to contain deficiencies which have not been corrected in accordance with NFPA 17 (2009). Service ticket dated 2/14/17 for "inspection" of the halon fire suppression system, 4th floor IT room, indicated the "initiator overdue for replacement, batteries test marginal and recommend replacement of batteries". |
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| VIOLATION: Illumination of Means of Egress | Tag No: K0281 | |
| Based on observation and staff interview, illumination of the exit discharge portion of the means of egress is not provided to maintain illumination of the means of egress in the event of failure of the normal power supply. This deficient practice could affect any patients, staff, and visitors in the building because the failure to maintain illumination of the means of egress can prevent safe and unimpeded access to the public way if there is an emergency. Findings include: A. On October 4, 2017 while in the company of the SDSS & AE, it was observed that not all exit discharge locations were provided with instant-on type lighting to provide illumination within the required 10 second period to comply with 19.2.8, 19.2.9 and 7.8 & 7.9.1.3. Not all locations were provided with two lamps or two fixtures to meet the requirements of 7.9.1.4. Locations observed include: 1. At 8:55am at the discharge of the southeast & northeast exit stairs. 2. At 11:25am at the Boiler room exterior exit door. 3. At 11:25am at the exterior door from the south ramp from the 1st floor level. 4. At 11:45am at the exterior door from the south center stair. 5. At 2:30pm at the north & northeast exterior doors of the emergency dept. addition. 6. At 2:45pm at the south exterior door of the emergency dept. a single fixture with only a single lamp was provided. |
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| VIOLATION: Exit Signage | Tag No: K0293 | |
| Based on observation, Exit signage is not provided to accurately identify access to Exits. Failure to accurately identify exit paths can confuse occupants and delay occupants from accessing the safety of an exit if there is a fire emergency. Findings include: A. On October 4, 2017 while in the company of the SDSS it was observed that exit signs and directional exit signs are not provided to accurately identify access to exits to comply with 19.2.10 and 7.10. Locations observed include: 1. At 10:05am, exit signage is not provided at the west end of the 1st floor corridor serving the Administration offices to comply with 19.2.4.3 and 7.10.1.2.1. 2. At 10:30am, visible exit signage is not provided at the south end of the corridor serving the elevators near the main lobby to comply with 19.2.4.3 and 7.10.1.2.1. 3. At 11:25am, directional signage is provided at the 1st floor Radiology suite 3-hour doors which misdirects access to an exit into a room in noncompliance with 19.2.4.3 and 7.10.1.5.1. 4. At 2:05pm, visible exit signage is not provide at the east and west ends of the south corridor serving the Pharmacy to comply with 19.2.4.3 and 7.10.1.2.1. 5. At 2:10pm, it exit signage is not provided at the west end of the corridor leading toward the emergency room to comply with 19.2.4.3 and 7.10.1.2.1. 6. At 2:30pm, visible exit signage in the emergency room suite was not provided to identify access to two separate exits to comply with 19.2.4.3 and 7.10.1.2.1. (Only one exit sign was observable from the west side of the suite. Signage installed at the north side of the suite appeared to be oriented incorrectly or provided inappropriately as directional signage.) |
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| VIOLATION: Hazardous Areas - Enclosure | Tag No: K0321 | |
| Based upon observation, hazardous areas are not protected in accordance with Code requirements. Failure to provide protection of areas with a higher degree of hazard than normal to the remaining occupancy can compromise the safety of all occupants during a fire/smoke event originating within the hazardous area. Findings include: A. On October 4, 2017 while in the company of the SDSS it was observed that hazardous areas did not have door assemblies which are in compliance with 19.3.2.1, 8.4.3.5 and 19.3.6.3.5. Sprinklered rooms did not have doors that are self-closing to a latched condition and nonsprinklered rooms did not have self-closing fire rated doors to afford the required enclosure of the hazardous area. Locations observed include: 1. At 9:10am at the sprinklered basement Bio-hazard room. 2. At 9:20am at the nonsprinklered basement Table Storage room. 3. At 9:30am at the nonsprinklered basement Bio-med shop. 4. At 9:45am at the sprinklered basement Med Record Storage room. 5. At 9:50am at the sprinklered basement EVS Storage room. 6. At 10:10am at the sprinklered basement Emergency Preparedness Equipment room. 7. At 10:20am at the nonsprinklered 1st floor Trash Holding room (in corridor south of Kitchen) the ceiling was missing to provide containment of the room. Based on observations of hazardous areas, the facility failed to provide separation between hazardous rooms from surrounding areas. This deficient practice could affect patients, staff and visitors if a fire could spread without proper fire separation. Findings include: B. On October 4, 2017, at 9:00 AM while accompanied by the CE, in review of the Life Safety drawings on 4th floor, soiled utility room 417 was indicated as 1-hour rated. The room contained metal pan ceiling which is not smoke or fire tight. The panels were painted in place and no access was provided to verify if the wall in the interstitial space was sealed to maintain the required rating. This does not comply with 19.3.2.1 & 8.3.5.1. C. On October 4, 2017, at 9:45 AM while accompanied by the CE, in review of the Life Safety Drawings on 4th floor, storage room 428 was indicated as 2 hour rated construction. The door on this room failed to close to the latched position, not meeting 8.3.3.1 & 8.3.3.3. D. On October 4, 2017, at 10:34 AM while accompanied by the CE, in review of the Life Safety Drawings on 3rd floor unoccupied unit, non-sprinklered patient room 306 was being utilized for bed and mattress storage. The room failed to meet the minimum 1-hour protection requirements for hazardous areas required by 19.3.2. |
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| VIOLATION: Fire Alarm System - Installation | Tag No: K0341 | |
| Based upon observation, fire alarm systems are not installed in accordance with Code requirements. Failure to properly install fire alarm systems can affect all occupants of the building by compromising the operation of the system to provide an effective warning if there is a fire/smoke event. Findings include: A. On October 4, 2017 at 9:35am while in the company of the SDSS it was observed that not all Fire Alarm control panels in the basement IT room were labeled to identify the panel and circuit from which they are fed to comply with NFPA 72-2010, 10.5.5.2.1. B. On October 4, 2017 at 10:00am while in the company of the SDSS it was observed that the "B2L3" electrical panel, located at the basement level corridor, served components of the Fire Alarm system. Not all circuits serving the Fire Alarm had red markings or lock-on devices to comply with NFPA 72-2010, 10.5.5.2.3 & 10.5.5.2.4. This panel was not a designated Life Safety Branch panel to comply with NFPA 99-2012, 6.4.2.2.3.2(7). C. On October 4, 2017 at 1:45pm while in the company of the SDSS it was observed that panel "1CL1" on the 1st floor served components of the Fire Alarm system. The circuits did not have red markings and the panel directory numbering system did not match the layout of the panel circuits to correctly identify the Fire Alarm circuit to comply with NFPA 72-2010, 10.5.5.2.3 & 10.5.5.2.4. This panel was not a designated Life Safety Branch panel to comply with NFPA 99-2012, 6.4.2.2.3.2(7). |
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| VIOLATION: Fire Alarm System - Initiation | Tag No: K0342 | |
| Based on observation, not all portions of the building's fire alarm system are installed as required. This deficient practice could affect any patients, staff, and visitors in the building because they could be delayed in activating the fire alarm system if not properly installed. Findings include: On October 4, 2017 at 2:00pm, while accompanied by the SDSS it was observed that the fire alarm manual pull station across from the main entry reception desk was not within 5 feet of either the interior exit door to the vestibule or the two exit doors from the vestibule to the exterior to comply with 9.6.2.3(1) and NFPA 72 2010 17.14.6. |
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| VIOLATION: Evacuation and Relocation Plan | Tag No: K0711 | |
| Based upon document review and staff interview, the facility's "Fire Plan" and "Fire-Plan of Action (Hospital wide)" policies do not clearly define the required response to a fire emergency. Failure to adequately identify and train staff in the required responses can impair prompt notification of emergency forces and compromise patient, staff and other building occupants' safety. Findings include: On October 3, 2017 at 1:10pm during review of the facility's policies in the company of the SDSS, the following irregularities were noted: 1. Page 4 of 7 states that the following announcement is made upon activation of the fire alarm system: "Code Red, Code Red, Code Red, Go to (location of fire) immediately." This announcement appears to direct occupants to the fire location rather than simply informing occupants of the location of the fire. The "Go to ..." announcement violates the principle of removing occupants or evacuating the area of the fire incident in accordance with 19.7.2.1. 2. Page 7 of 7 states that "Reports of fire will be forwarded to Safety Officer for presentation to the Environment of Care Committee." Any fire incident is also required to be reported to IDPH to comply with 250.1520(f) and the notification procedures of 19.7.2.2. 3. Page 1 of 7 and page 6 of 12 references the 2006 and 2000 editions of the NFPA 101 Life Safety Code when the 2012 edition is currently being enforced. 4. Page 7 of 12 references "How and under what conditions they activate the fire alarm or call a Code Red." and "When it would be necessary to call 911 to alert the Fire Dept." Activation of the fire alarm is a required response under any actual or suspected fire emergency to comply with 19.7.2.1.2(2) and 19.7.2.2(3). |
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| VIOLATION: Fire Drills | Tag No: K0712 | |
| Based on document review, fire drills are conducted but staff has not been properly trained. This deficiency could affect any patients, staff, or visitors in the building because the staff failed to react as required under emergency conditions. Findings include: On October 3, 2017 at 1:45 PM, it was noted on several fire drills that the staff failed to follow procedures or did not know what to do during the fire drills. A resolution was not provided as to how this deficiency has been or will be corrected for future tests not meeting with 19.7.1.2. |
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| VIOLATION: Electrical Systems - Other | Tag No: K0911 | |
| Based on observation, the facility failed to install the building's Essential Electrical System (EES) as required. This deficient practice could affect patients, staff and visitors in the building because life support equipment could fail to operate under emergency conditions if the EES is not installed properly. Findings include: A. On October 4, 2017 at 9:29 AM, while accompanied by CE, it was observed that the 4th floor OR room 416 failed to contain battery-powered emergency lights required by NFPA 99 (2012), 6.3.2.2.11.1 and NFPA 70 (2011) 517-63A. Based on observation, not all portions of the building's electrical system are maintained in accordance with Code requirements. This deficient practice could affect any occupants of the building that may come in contact with the unprotected electrical components that are improperly maintained. Findings include: B. On October 4, 2017 at 1:40pm while in the company of the SDSS, it was observed that the electrical room behind the Pharmacy had loose wire, connections and fixtures not contained within the conduit system and not secured in accordance with NFPA 70-2011, 300.11. |
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| VIOLATION: Electrical Systems - Essential Electric Syste | Tag No: K0918 | |
| Based upon record review, staff interview & observation, the emergency generator systems are not maintained in accordance with Code requirements. Failure to maintain generators can result in failure of the system to perform as needed during a failure of the building's normal utility power supply. Findings include: A. On October 3, 2017 at 2:00pm during record document review of the emergency generator testing logs and through interview with the SDSS & SE, it was determined that periodic testing under load of 2 of 3 emergency generators in accordance with NFPA 110-2010, Chapter 8 is not being performed or documented. 1. Only testing under load of the generator serving the main hospital is being tested on an approximate monthly basis and required load bank testing of this generator is past due as of August 2016. The August 2016 load bank testing documentation indicates that the generator could only be loaded to 50% capacity for 1 minute, and not the minimum 75% for 1 hour required by 8.4.2.3. 2. The generator for the new Emergency Dept. addition is not being tested under load and documented on approximately a monthly schedule. Staff indicates the generator is exercised weekly, but no documentation of loading or load bank testing was available for review to comply with 8.3 & 8.4. 3. The generator for the fire pumps is not being tested under load and documented on approximately a monthly schedule. Staff indicates the generator to be tested under load only when the annual fire pump testing is performed. This does not comply with the requirements of 8.3 & 8.4. B. On October 4, 2017 it was observed while in the company of the SDSS that the Essential Electrical Systems are not separated into distinct branches to comply with NFPA 99-2012, 6.4.2.2. See K341 as an example of Life Safety loads (fire alarm system) fed from a Critical branch panel. The full extent of the mixed load condition was not determined during the survey. |
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| VIOLATION: ALCOHOL BASED HAND RUBS | Tag No: K0211 | |
| Based upon observation, means of egress are not maintained in accordance with requirements. Failure to maintain means of egress can result in impediments to use of the exit or access to the exit discharge from the building. Findings include: On October 4, 2017 at 3:00pm it was observed while in the company of the SDSS & CE that the 2nd floor landing of the north stair was used for the storage of housekeeping equipment and materials in non-compliance with 39.2.2.3.1, 7.2.2 & 7.1.3.2.3. |
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| VIOLATION: Emergency Lighting | Tag No: K0291 | |
| Based upon observation, the emergency lighting provided is not maintained in accordance with requirements. Failure to maintain functional emergency lighting can result in occupants inability to identify and negotiate travel to the means of egress from the building when normal lighting has failed. Findings include: On October 4, 2017 while in the company of the SDSS & CE it was observed that 4 of the 5 battery powered emergency lighting units tested failed to operate to comply with 7.9.2 & are not being periodically tested to comply with 7.9.3. |
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| VIOLATION: Exit Signage | Tag No: K0293 | |
| Based upon observation, exit signage is not maintained in accordance with requirements. Failure to maintain illuminated exit signs can result in occupants not being able to readily identify the means of egress from the building. Findings include: On October 4, 2017 at 3:15pm while in the company of the SDSS & CE it was observed that not all internally illuminated exit signs were provided with functional lamps to comply with 39.2.10, 7.10.5.1, & 7.10.7.1. Observed locations include the 2nd floor waiting room and the south stair. |
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