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(1) Based on observation and interview, the facility failed to ensure that all corridor doors were provided with approved positive latching hardware. NFPA 101-2000 Life Safety Code Section 19.3.6.3.2 requires that corridor doors in Existing Health Care Occupancies be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction (e.g., doors shall be provided with positive latching hardware). Specific reference is made to the lack of positive latching hardware (e.g., automatic flush bolts).

Findings:

On 05/04/15, at approximately 10:00 AM, the inactive leaf of double doors on the cystocscopy room in the Operating Room (OR) suite was found to be provided with concealed manually operated flush bolts that would take more than one (1) operation to secure in the event of a fire.

This was also observed on the inactive leaf of a double door on the pre-op room (across from the cystoscopy room)

In an interview on 05/04/15 at approximately 10:30 AM, Director of Facility Management stated that they would change the doors and will have automatic flush bolts on the new doors.
42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.6.3.2


(2) Based on observation and interview, the facility failed to ensure that all corridor doors were provided with approved positive latching hardware. NFPA 101-2000 Life Safety Code Section 18.3.6.3.3 requires that there is no impediment to the closing of corridor doors in New Health Care Occupancies. If facility building plans were approved, or a building permit issued, or construction started after March 13, 2003, the building or addition must be surveyed under the 2000 New Health Care Occupancy Chapter. Specific reference is made to the Anesthesia storage room of the operating suite.

Findings:

On 05/05/15 at approximately 10:30 AM, it was observed that the storage room door did not positively latch.

In an interview on 05/05/15 at approximately 10:45 AM, Director Of Facilities Management stated that the facility is in the process of examining all doors in the facility

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 18.3.6.3.3

2000 NFPA 101: 8.2.5.4*
The fire resistance rating for the enclosure of floor openings shall be not less than as follows (see 7.1.3.2.1 for enclosure of exits):
(1) Enclosures connecting four (4) stories or more in new construction - two (2) hour fire barriers.
(2) Other enclosures in new construction - one (1) hour fire barriers.
(3) Existing enclosures in existing buildings - one-half (½) hour fire barriers.
(4) As specified in Chapter 26 for lodging and rooming houses, in Chapter 28 for new hotels, and in Chapter 30 for new apartment buildings.


Based on observation and interview, the facility failed to ensure that the enclosure for the staircase in the basement leading to the Central Sterile was provided with a two (2) hour fire barrier.

Findings:

On 05/07/15 at approximately 1:45 PM, the enclosure for the staircase leading to Central Sterile was found with 4 big holes of 6-8 inches in diameter on a two (2) hour fire barrier enclosure and two (2) unsealed conduit penetrations were noted above the door in the ceiling.

In an interview on 05/07/15 at this time, the Manager stated that the holes in the wall of the enclosure and the conduit penetrations would be sealed immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 8.2.5.4
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2000 NFPA 101: 19.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than one-half (½) hour.


Based on observation and interview, the facility failed to ensure that smoke barrier walls were constructed to have at least a one-half (½) hour fire resistance rating in smoke barrier walls on the 3rd floor of Brigger, basements of Brigger and Minkin buildings. Conditions observed included, but were not limited to, unsealed penetrations around wires and conduits, cut holes, and improperly sealed and unfinished wall assemblies.

Findings:

During facility tours conducted between 05/04/15 and 05/11/15, unsealed penetrations around wires and conduits, cut holes, and improperly sealed and unfinished wall assemblies were noted in smoke barrier walls. Examples include, but are not limited to the following:

During the tour of the Emergency Department in the Annex building on 05/04/15 at approximately 11:30 AM, it was noted the wall separating the triage room and the 20 treatment bays from the waiting area did not go up to the deck above the ceiling tiles and was not continuous from wall to wall.

The facility's Life Safety drawing did not match the actual layout of the emergency department (ED).

During the tour of the soiled utility room of the Emergency Department, it was noted that the wall enclosure was not a 1 hour rated wall, in that the wall does not extend to the deck above the dropped ceiling.

The electrical closet outside the Operating Rooms had penetrations in the ceiling of approximately 5 inches in diameter around conduit passing through the ceiling.

During the tour of the Brigger 3rd Floor, penetration of approximately 1/2 inch due to penetrating conduit was noted above smoke door SD 09.

During the tour of the Central sterile the smoke barrier wall along the corridor did not extend to the deck above the dropped ceiling.

During the tour of the radiology unit in the basement of Minkin building, the smoke barrier wall above the smoke door SD 28 did not extend to the ceiling above the dropped ceiling.

During the tour of the basement of the Brigger building, penetration around the waste pipe was noted above the smoke door SD 33.

During the tour of 4th floor of Brigger building, the penetrations in the corridor wall of the linen closet (across from room 442) was observed to be plastered with non-fire rated material.

In an interview on 05/11/15 at approximately 11:39 AM, the Director of Facility Management stated that the facility had identified all or most of the penetrations and were in the process of applying fire stoppings and sealing them.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.7.3, 8.3, 8.2.3.

Based on observation and interview, the facility failed to ensure that all door openings in fire barriers were protected by self-closing, positive latching doors.

Findings include:

During the tour of the 3rd floor of Minkin building on 05/08/15 at approximately 11:00 AM, it was observed that the door of the fire barrier separating Minkin building from Katz did not have the hardware that was capable of self closing and positive latching.

Interview with the Manager of the Engineering Department at this time stated that the hardware would be purchased and installed immediately.


Based on observations and staff interview, the facility failed to ensure that all the door openings in smoke barrier are protected with proper fire rated doors.

Findings include:

During the tour of the 3rd floor of Brigger on 05/08/15 at approximately 2:00 PM, it was noted that the smoke door SD09 was rated for 20 minutes, instead of 1/4 hour as required.

This was brought to the attention of the Director of Facility Management, who stated that the the facility will replace that door immediately.


Based on observation, record review and staff interview, the facility failed to maintain the smoke partition of the CAT Scan room (trailer).

During review of the Fire Alarm testing records for 2014, it was noted that the vendor (Pyro Signal) had noted that the CAT Scan room was not air-tight.

During the tour of the unit on 05/08/15 at approximately 2:30 PM, it was noted that the smoke partition between the CAT Scan room and the patient waiting area did not extend to the deck. It stopped 12 inches short of the ceiling above the dropped ceiling. The door was also observed to be rated for 20 minutes.

2000 NFPA 101 LSC Chapter 19.3.5 Extinguishment Requirements 19.3.5.1
Where required by 19.1.6, Health Care Facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
9.7 AUTOMATIC SPRINKLERS AND OTHER EXTINGUISHING EQUIPMENT
9.7.2 Supervision
9.7.2.1* Supervisory Signals
Where supervised automatic sprinkler systems are required by another Section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.


Based on observation and interview, the facility failed to ensure that all sprinkler control valves were electronically supervised to sound an alarm at a continuously monitored location. This was evidenced by electronic supervisory devices noted not being provided on sprinkler control valves in-line of a sprinkler pipe located in the stairwell landing of Brigger basement.

Findings:

On 05/06/15 at approximately 9:30 AM, electronic supervisory devices were observed not provided on sprinkler control valve L5 in-line of a sprinkler pipe located in the stairwell landing of Brigger Basement.

In an interview on 05/07/15 at approximately 9:30 AM, Director of Facility management stated that they would have the company install the tamper switches immediately.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 9.7.2.1, 19.3.5.1
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1998 NFPA 96- Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 7.2.2.1
Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and the following standards where applicable.
(1) NFPA 12, Standard on Carbon Dioxide Extinguishing Systems
(2) NFPA 13, Standard for the Installation of Sprinkler Systems
(3) NFPA 17, Standard for Dry Chemical Extinguishing Systems
(4) NFPA 17A, Standard for Wet Chemical Extinguishing Systems


1998 NFPA 17A- Standard for Wet Chemical Extinguishing Systems 5.2 Owner's Inspection 5.2.1
Inspection shall be conducted on a monthly basis in accordance with the manufacturer's listed installation and maintenance manual or the Owner's Manual. As a minimum, this "quick check" or inspection shall include verification of the following:
(1) The extinguishing system is in its proper location.
(2) The manual actuators are unobstructed.
(3) The tamper indicators and seals are intact.
(4) The maintenance tag or certificate is in place.
(5) No obvious physical damage or condition exists that might prevent operation.
(6) The pressure gauge(s), if provided, is in operable range.
(7) The nozzle blowoff caps are intact and undamaged.
(8) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.


Based on observation, interview and documentation review, the facility failed to ensure that the required monthly inspections of the Dry Chemical Extinguishing System installed in the trailer CAT Scan room are performed.

Findings:

On 05/08/15 at approximately 3:00 PM, it was observed that the last documented Dry Chemical extinguisher inspection was completed on 02/08/15 as noted by tags on the canister located on the wall of the CAT Scan room. There were no documented monthly inspections noted prior to and since the service date.

In an interview on 05/08/15 at this time, the Manager of the Engineering Department stated that the vendor would be notified immediately and the Dry Chemical Extinguishing System would be inspected.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.3.2.6, 9.2.3, 1998 NFPA 96: 7.2.2.1, 1998 NFPA 17: 5.2.1.

(1) Based on observations and staff interview, the facility failed to monitor the abnormal alarm signal on the Medical Gas Master Alarm panel installed in the boiler room.

Findings include:

During the tour of the Boiler room on 05/08/15 at approximately 3:30 PM, it was noted that there were two red lights on the Master alarm panel. One red light was observed to be labeled as low Liquid Oxygen and other was unlabelled.

It was also noted that this alarm panel did not emit an audible signal.

During concurrent interview of a Per-Diem Stationary Engineer (responsible for monitoring the system at that time) it was revealed that this employee was not aware of the type of alarm and the time it originated. This employee did not report the alarm to the hospital authorities and the facility did not have documented evidence of alarm acknowledgement or as being reported to appropriate department or authority.

Interview of the Manager for Engineering Department revealed that there was a second master alarm panel installed in the hospital's telephone operator's room. During tour and observation of this room on 05/11/15 at approximately 10:30 AM, it was noted that there was one red light on the panel. Upon interview of the telephone operators, it was revealed that the low liquid oxygen alarm was reported and action was taken by the facility. The second ongoing alarm was stated to be a false alarm for suction pressure. It was stated that the vendor was notified of the alarm and was called to resolve the issue. The audible signal was muted on this panel.

Therefore, it was determined that the facility failed to monitor the Medical Gas Master Alarm Panels continuously by trained individuals, to ensure safe delivery of Medical gas during patient treatments and medical procedures.



(2) Based on observations and staff interview, the facility failed to ensure that the Medical Gas System consisted of all the required components and that it was fully operational without having two operating room (OR) medical gas pipelines being interconnected. Specific reference is made to the fact that the facility failed to install the Waste Anesthetic Gas Disposal (WAGD) inlet in the Operating Rooms and in the two endoscopy procedure rooms.

Findings include:

During the tour of the endoscopy procedure rooms on 05/05/15 at approximately 11:30 AM, it was noted that the medical gas line for waste oxygen and nitrous oxide gas was being held together by tape and connected to a suction line dropping from the ceiling.

Upon interview of the Director of Facilities and the Manager of the Engineering Department, it was revealed that the facility did not have inlets for Waste Anesthetic Gas disposal.

Upon further investigation, it was revealed that the facility did not have inlets for WAGD in the 4 Operating Rooms and the Cystoscopy room.


Further interviews with the Director of Facility Management and the Manager of Engineering Department on 05/06/15 revealed that the vendor for Medical Gas System was called to install the WAGD inlets and the work order was provided to the surveyor for all the anesthetizing locations.

Based on observation, documentation (i.e., Panel Board Schedule) review and interview, the facility was not provided with a Type 1 Essential Electrical System that was divided into separate Critical Branch, Life Safety Branch and Equipment Systems in accordance with NFPA 99. This was noted throughout the facility.

Findings include:

Examples include, but are not limited to, the following:

a) On 05/04/15 at approximately 12:30 PM, review of the Emergency Power Panel Directory for Panel "EER-1" in the 1st Floor Electrical Room revealed that this Panel served all three branches of Emergency System-Life Safety Branch Loads (e.g., Corridor Lights, Dampers, Exit Lights), Emergency System-Critical Branch Loads (e.g., Pharmacy equipment, Nurses station) and Equipment Branch Loads (Condensation pumps). As per a concurrent interview with the Manager of the Engineering Department, it was confirmed that the hospital's emergency power was not divided into the three required branches.

b) On 05/05/15 at approximately 10:28 AM, review of the Emergency Power Panel Directory for Panel "ECP 5A" in the Endoscopy area located in Katz building 5th floor revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Exit Hall Lights, Oxygen Alarms) and Emergency System-Critical Branch Loads (e.g., Nurses' Call System). As per concurrent interview with the Manager of the Engineering Department and Director of Facility management , they will notify facility Administration concerning this condition.

c) On 05/05/15 at approximately 10:30 AM, review of the Emergency Power Panel Directory for Panel "ELP5A" in the Endoscopy area located in Katz building 5th Floor revealed that this Panel served both Emergency System-Life Safety Branch Loads (e.g., Fire Exit lighting) and Emergency System-Equipment Branch Loads (e.g., AC Fan, Refrigerator.). As per interview with the Electrician of the facility on 05/11/15 at approximately 12:00 noon, it was found that the facility's emergency power is not divided into separate three branches. It was also stated that the new Psychiatric Unit on Minkin 5th floor is served with the three separate branches of the emergency power at the distribution panels.


42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 4.6.1.2, 19.5.1, 9.1.2, NFPA 99-1999 Standard for Health Care Facilities: 12-2.5, 12-3.3, 3-4.2.2, NFPA 70-1999 National Electrical Code: Article 517, Article 700-9, NFPA 76-1967, Essential Electrical Systems for Hospitals: Article 541 and NFPA 76A-1973, Essential Electrical Systems for Health Care Facilities: Article 551, NFPA 70-1965, National Electrical Code: Article 700-9, NFPA 70-1968, National Electrical Code: Article 700-9, NFPA 70-1971, National Electrical Code: Article 700-9

10NYCRR, 405.24(b), 711.2(a)(1), 711.2(a)(20)
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1) Based on observation and interview, the facility failed to ensure that outlets served by the Emergency System were provided for equipment used for Critical Laboratory testing.

Findings:

On 05/11/15 at approximately 10:00 AM, it was noted that there were no outlets installed that were served by the emergency generator.

In an interview on 05/11/15 at this time, the Manager of the Engineering Department stated that the facility was working with a vendor to provide emergency power to the laboratory.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 517-19


2) Based on observation and interview, the facility failed to ensure that flexible cords and cables were not used as a substitute for the fixed wiring of a structure. This was noted in the Emergency Department and the Operating Rooms

Findings:

From 05/04/15 through 05/11/15, between 9:00 AM and 4:00 PM, the following was noted:

a) Relocatable power strips were noted in Operating Rooms (ORs) including, but not limited to, OR #4.

b) A relocatable power strip was noted in the Waiting room of the Emergency Department.

c) An extension cord was noted in the Registration Room of the Emergency Department.

During interview on 05/04/15 at approximately 11:45 AM, the Director of Facility management stated that the facility may have relocatable strips in many other areas and that he had not yet made an assessment of their use and therefore did not make any changes.

42 CFR 482.41(b), NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-3, 400-8