HospitalInspections.org

Based on observation the facility failed to ensure that the smoke doors were maintained in a manner to resist the passage of smoke.

Findings include:

Ondate of 07/23/14, at 1:30 PM and 3:00PM , the smoke partition held open door in front of the kitchen doors between the corridor and the smoke barrier door outside the intensive care unit did not close in a manner to resist the passage of smoke. A gap of approximately 1/2'' was noted at the meeting edges.

Based on review of documents and staff interview, the hospital failed to ensure that all staff is trained in all aspects of fire safety by qualified personnel. Specific reference is made to the fire drills conducted by a dentist at the dental clinic.

Findings include:

Review of the fire drill records revealed that the Director of Dental services at this clinic was conducting the fire drills quarterly.

Interview of this employee revealed that this employee did not have certificate of fitness from FDNY to conduct fire drills.This practice is in violation of the local law.

The Director of Safety at the hospital confirmed that his department was not involved in conducting the fire drills at the clinic.

Based on review of documents and staff interview, the facility failed to maintain all the components of the fire alarm system in good repair.

Findings include:

Review of the inspection report of the fire and smoke dampers revealed that the inspection was conducted in April 2012 and that approximately 50 percent of the dampers had failed due to reasons which include: being jammed, having an inoperable actuator, or not being accessible. There was no repair or appropriate follow-up actions taken until September 2013.

Review of the repair report of September revealed that Life Safety Service (a contract company) did not repair or replace 50 percent of the failed damper actuators.

Interview of the Director Of Engineering on 07/29/14 at approximately 11:00 AM revealed that the facility was not aware of the incomplete repair/testing work conducted by the vendor.

There was no documented evidence that the facility implemented an Interim Life Safety Plan to ensure patient safety in the event of fire while the smoke dampers are under repair.