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||Aug. 4, 2021|
|VIOLATION: Electrical Systems - Essential Electric Syste||Tag No: K0915|
|Based upon observation and staff interview, not all patient bed locations are provided with electrical power in accordance with Code requirements. Failure to provide electrical power at patient bed locations can disrupt use of bedside equipment used by patients.
A. On 8/3/21 at 3:25pm while in the company of the DF & ACE it was observed that the 4th floor OB Critical Care Delivery rooms #1 & #2 lacked both normal power and emergency power to comply with NFPA 70-2011, 517-19(A) because:
1. Delivery room #1 lacked normal power receptacles or confirmation that the room was served by two different emergency power transfer switches.
2. Delivery room #2 lacked critical branch emergency power receptacles.
|VIOLATION: Electrical Systems - Essential Electric Syste||Tag No: K0918|
|Based on staff interview/document review, required essential electrical equipment inspection and testing is not being conducted. This deficient practice could affect patients, staff and visitors during a utility outage or fire event.
The findings are:
On 8/3/21 at 11:55am in the company of the DF, documents could not be provided to indicate the weekly inspection and monthly testing under load for both the Emergency Department Generator and Fire Pumps Generator had been completed. NFPA 110, 2010, 8.4.1
|VIOLATION: Exit Signage||Tag No: K0293|
|Based on staff interview and document review, exit signage inspections are not being conducted as required. This deficient practice could affect patients, staff, and visitors during a fire event if exit signs fail to provide occupants identification of exits and exit paths.
The finding is:
On 8/3/21 at 12:45pm in the company of the DF & CE documents could not be provided to indicate the illuminated exit signs are visually inspected at least once every 30 days to comply with 188.8.131.52.
|VIOLATION: Electrical Systems - Other||Tag No: K0911|
|Based upon observation, Electrical systems are not maintained in accordance with Code requirements. Failure to maintain electrical systems can result in shock hazard to occupants upon contact with electrical components.
On 8/3/21 at 1:40pm while in the company of the DF & ACE it was observed at the 5th floor south staff lounge that a junction box above the door with wiring connections lacked closure of the box with a cover plate to comply with NFPA 70-2011, 314.28(C).
|VIOLATION: Vertical Openings - Enclosure||Tag No: K0311|
|Based an observations, not all exit doors are installed or maintained to provide protection of the exit enclosure. This deficiency could affect patients, staff and visitors if the exit access door did not provide the proper protection during a fire emergency.
The finding is:
On 8/3/2021 at 3:00pm, while accompanied by the AE, it was observed that the second floor Northwest Stair door failed to self-close and self-latch. This does not comply with the requirements of Table 184.108.40.206 and NFPA 80, 2010 220.127.116.11.
|VIOLATION: Egress Doors||Tag No: K0222|
|Based upon observation, egress doors are not maintained in accordance with Code requirements. Failure to maintain egress doors can impair occupants ability to exit from the building or area during an emergency condition.
A. On 8/3/21 at 1:45pm while in the company of the DF & ACE it was observed that the 5th floor door to the 4th floor roof was equipped with a panic device to permit free access to the roof but required a key to re-enter the building. Although the panic device was dogged in the unlatched condition, staff indicated that the door is regularly undogged and latched after hours. This arrangement does not comply with 18.104.22.168.9 because the roof can be freely accessed by the panic device but does not allow re-entry from the outside without a key.
B. On 8/3/21 at 3:05pm while in the company of the DF & ACE it was observed that the 4th floor OB Dept. has magnetic locking devices at the west cross corridor doors identified as a required exit from the OB corridor. The locks did not function in accordance with the provisions of 22.214.171.124.4. The following was observed during testing of the devices:
1. The magnet(s) did not release in accordance with the provisions of 126.96.36.199.1 for Delayed Egress Locking Systems. A remote release at the nurse station appeared to be the only means to release the locks. The provisions of 188.8.131.52.5.2 were not otherwise observed to be met.
2. The building is not protected throughout by a fire detecion system or a sprinkler system to comply with 184.108.40.206.1.1 for use of Delayed Egress system. The provisions of 220.127.116.11.5.2(3) for the building to be protected by an approved sprinkler system were not otherwise met. The provisons of 18.104.22.168.5.2(3) permitting as a minimum the smoke compartment containing the locked space and any adjacent smoke compartment providing egress for the locked space to be sprinklered were not met.
3. Signage required by 22.214.171.124.1.1(4) was not provided on the doors if a Delayed Egress system was being utilized.
4. It was not confirmed if release of the locking system by fire detection system or sprinkler system activation was provided to comply with 126.96.36.199.1.1(1) or 188.8.131.52.5.2(5).
C. On 8/4/21 at 10:55am while in the company of the AE it was observed that the Elevator which opens into the 1st floor Kitchen was provided with a gate assembly which was padlocked after hours to prevent access to the Kitchen by way of the elevator. Interview with Staff and the CE could not positively determined the primary and secondary level of discharge for the Elevator Recall system but it was believed to be the 1st floor Kitchen level and Basement level. The locked gate has the potential to take occupants to the discharge level during Elevator Recall operation and not allow them to exit the elevator due to the locked gate. 184.108.40.206 is not met.
|VIOLATION: Stairways and Smokeproof Enclosures||Tag No: K0225|
|Based upon observation, Stairways are not maintained in accordance with Code requirements. Failure to maintain Code compliant stairways can impair building occupants' use of the stair for egress from the building during a fire/smoke event.
A. On 8/3/21 at 2:45pm while in the company of the DF it was observed that the Northwest stair serving 5 stories lacked guard railings that restricted passage of a 4" sphere to comply with 220.127.116.11.5.3. The stair runs are approximately 18" apart which is greater than the 12" permitted by CMS for approved existing stairs to permit open guards.
B. On 8/3/21 at 3:20pm while in the company of the DF & ACE it was observed that the Northeast stair contained a closet space to separate the electrical panels from the stair enclosure to comply with 18.104.22.168.1 but the door to the closet did not self-close to a latched condition to comply with NFPA 80 requirements.
C. On 8/4/21 at 11:00am while in the company of the AE it was observed that the Northeast stair door at the 2nd floor level was held open in non-compliance with 22.214.171.124.8 and 126.96.36.199.1 because the door drags on the floor stop.
D. On 8/4/21 at 11:00am while in the company of the AE it was observed that the Northeast stair exterior exit discharge door sticks in the frame to prevent ease of opening in non-compliance with the force requirements of 188.8.131.52.5.1.
E. On 8/4/21 at 11:00am while in the compancy of the AE it was observed that the gates provided at the Northeast stair to comply with 184.108.40.206 were not functioning to provide a barrier against movement below the level of exit discharge.
F. On 8/4/21 at 10:35am while in the compancy of the AE it was observed that the gates provided at the Southeast stair to comply with 220.127.116.11 were not functioning to provide a barrier against movement below the level of exit discharge.
G. On 8/4/21 at 10:35am while in the compancy of the AE it was observed that the Southeast stair contained a newer installed approximate 2' x 2' electrical pull box and multiple conduit runs within the stair enclosure in non-compliance with 18.104.22.168.1. This location also had several bags of Quickcrete material stored in the stair enclosure in non-compliance with 22.214.171.124.3.
|VIOLATION: Electrical Systems - Receptacles||Tag No: K0912|
|Based upon observation, ground fault circuit interruption (GFCI) is not provided in accordance with Code requirements. If GFCI protection is not provided, the circuit remains an electrical shock hazard to occupants. This deficient practice could affect the safety of patients, staff, and visitors.
On 8/3/2021 at 2:30pm, while in the company of the AE it was observed in the third floor east Soiled Holding room that an electrical receptacle is within 6'-0" of a clinical sink fixture and is not provided with GFCI protection to comply with NFPA 70 2011, 210.8(B)(5).
|VIOLATION: Discharge from Exits||Tag No: K0271|
|Based upon observation, exit discharges are not maintained in accordance with Code requirements. Failure to maintain exit discharge conditions for safe travel from the building can compromise the safety of occupants during exiting from the building.
A. On 8/3/21 at 3:15pm while in the company of the DF & ACE it was observed that the 4th floor OB Dept. had an identified exit path to the east door to the roof to access the Southeast stair. The following conditions were observed:
1. The path across the roof was provided with 2" thick concrete pavers space approximately 2" apart to create gaps in the walking surface which presents a tripping hazard not in compliance with 7.1.6 and 7.1.10.
2. The lighting provided for this path could not be confirmed to meet the requirements of 19.2.8, 19.2.9 and 7.8 & 126.96.36.199 because staff believed lighting to be HID lamps requiring a restrike/warm-up delay.
B. On 8/4/21 at 11:10am while in the company of the AE it was observed at the 1st floor north Staff entry exit discharge canopy that lighting provided could not be confirmed to be of the instant-on type to provide illumination within the required 10 second period to comply with 19.2.8, 19.2.9 and 7.8 & 188.8.131.52 because staff believed lighting to be HID lamps requiring a restrike/warm-up delay.
|VIOLATION: Hazardous Areas - Enclosure||Tag No: K0321|
|Based upon observation, hazardous areas are not properly separated from the remainder of the occupancy and the means of egress. Failure to properly separate storage of combustible material (which represents a degree of hazard greater than that normal to the general occupancy due to quantity and density of materials) from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material to compromise the use of the adjacent corridor for exiting.
A. On 8/3/21 while in the company of the DF & ACE it was observed that areas used for storage of combustible materials are not separated to comply with NFPA 101-2012, 184.108.40.206. Locations observed include:
1. At 1:40pm the non-sprinklered 5th floor south rooms used for a lounge space and an adjacent storage room were not maintained as a separated Hazardous Area because the door to the storage room was not a minimum 3/4-hour rated self-closing door. Alternatively, if both rooms are considered the Hazardous Area, the fire rated self-closing corridor door to the lounge space was being held open by a non-approved hold-open device (wedge) in non-compliance with 220.127.116.11.1.
2. At 2:00pm the non-sprinklered 5th floor former Operating rooms "C" & "D" which are being used for storage of supplies & equipment were observed not to be separated by 1-hour rated construction because the corridor doors to these rooms lacked minimum 3/4-hour fire rated door assemblies and are not positive latching to comply with 18.104.22.168.5 as corridor doors. The door at OR "C" also had a hasp and padlock installed on the door which does not comply with 7.1.9, 22.214.171.124.3 and 126.96.36.199.4 because it can prevent use of the door for egress.
3. At 3:00pm the non-sprinklered 4th floor west wing file storage room corridor door was observed to be held open by a bookcase positioned so as to wedge the door in the fully open position. This does not comply with 188.8.131.52.1.
B. On 8/4/21 while in the company of the AE it was observed that a >32 gallon capacity trash cart was unattended and stationed in the corridor outside the 1st floor Kitchen in non-compliance with 184.108.40.206.1.
|VIOLATION: Fire Alarm System - Installation||Tag No: K0341|
|Several smoke detectors throughout the hospital are not located as required for a compliant fire alarm system installation. Failure to locate devices accordingly may result in failure or delay of alarm initiation device during an emergency event. If alarm initiating devices do not function properly, then the building occupants may not be alerted to an emergency which may result in occupants' safety being compromised.
A. It was observed at various locations that detectors are located where airflow may prevent normal operation of the device as stated in NFPA 72 2012 220.127.116.11. Locations & conditions observed include the following:
1. At 1:43pm on 8/3/21, while in the company of the AE, it was observed that 2 smoke detectors were within 3"-0" of a HVAC diffusers in the hallway adjacent to the waiting area in the third floor ACU suite.
2. At 1:54pm on 8/3/21, while in the company of the AE, it was observed that a smoke detector was within 3"-0" of an HVAC diffuser at the east end of the hallway in the third floor ACU suite.
B. It was observed at 2:10pm on 8/3/21 while in the company of the AE, that a ceiling mounted smoke detector in the 3rd floor central shower room open to the interstitial space above where smoke can escape the enclosure which may prevent normal operation of the device. The installation is therefore out of compliance with in NFPA 72 2012 18.104.22.168.4.2.
|VIOLATION: Sprinkler System - Installation||Tag No: K0351|
|Based on observation the facility failed to maintain sprinkler system as required. Failure to maintain the system could result in delayed response and fire suppression. This deficient practice could affect patients, staff, and visitors during a fire event.
The finding is:
On 8/4/2021 at 10:42am while in the company of the DF, CE, & AE, the surveyor observed a missing cap on a concealed sprinker head above the emergency room entrance doors. This does not comply with NFPA 13, 2010 22.214.171.124.
|VIOLATION: Portable Fire Extinguishers||Tag No: K0355|
|Based on observation the facility lacks 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 8/4/21 at 11:05am while in the company of the AE it was observed that the installed Type 'K' fire extinguisher lacked signage for the correct sequence and use of the 'K' fire extinguisher located near the grease hood in the Kitchen to comply with NFPA 96-2011, 10.2.2.
|VIOLATION: Corridor - Doors||Tag No: K0363|
|Based upon observation, corridor doors are not maintained to provide separation of spaces from the means of egress Corridors. Failure to provide proper separation can compromise the use of the corridor as a means of egress in the event of a fire/smoke condition originating in spaces served by the corridor.
A. On 8/3/21 at 2:00pm while in the company of the DF & ACE it was observed that the corridor doors at the 5th floor OR "A" & OR "B" lacked positive latching hardware to comply with 126.96.36.199.5. See K321 for former OR "C" and "D" used as storage rooms with same condition.
B. On 8/3/21 at 2:30pm while in the company of the DF & ACE it was observed that the 4th floor ICU suite pair of corridor doors lacked positive latching hardware to comply with 188.8.131.52.5.
C. On 8/3/21 at 2:50pm while in the company of the DF it was observed that the 4th floor corridor door at the "Sicklecell & Oncology Treatment Center" was a plate glass door assembly which lacked stops at the head & jambs which does not provide resistance to the passage of smoke to comply with 184.108.40.206.1 and lacked positive latching hardware to comply with 220.127.116.11.5. Only a keyed lock that engaged at the floor was provided.
D. On 8/3/21 at 3:20pm while in the company of the DF & ACE it was observed that the Janitor room adjacent the 4th floor Delivery rooms had a louver in the door in non-compliance with 18.104.22.168.1. The exceptions permitted by 22.214.171.124.2 are not applicable when the observed Janitor room contained housekeeping trash collection containers not meeting the size/density requirements of 126.96.36.199.1.
E. On 8/3/21 at 3:22pm while in the company of the DF & ACE it was observed that the 4th floor Delivery room #2 corridor door latch was taped to prevent latching in non-compliance with 188.8.131.52.5.