HospitalInspections.org

Based on observation the facility's corridors did not always resist the passage of smoke.

Finding:

1. On the afternoon of 4/19/11 the dutch door to the payroll department was noted to lack an astragal to cover the gap approximately 1/4" at the meeting edges between the top and bottom doors. The payroll office is located in the same corridor as the entrance to the radiology suite.
.

Based on observation the hospital did not ensure that all vertical openings between floors are closed.

Findings:

1. During a tour of the outpatient clinic on the morning of 4/18/11 incompletely sealed penetrations were noted around 4" conduit penetrating the electrical closet floor.

2. A area of sheetrock approximately 6" by 6" was noted cut away from the back wall of the plumbing shaft adjacent to a 2" copper pipe. The plumbing shaft was located between room A 21 and the nurses's station.

3. Vertical shafts, requiring a 2 hour fire separation, were not identified on the floor plans that include the life safety legend.
.

Based on observation access to exits were not marked by approved, readily visible signs.

Finding:

During a tour of the power plant on the morning 4/20/11 it was noted that the way to exit doors was not readily visible from all areas.
.

Based on observation the facility did not ensure that hazardous areas are protected as required.

Findings:

1. During a tour of hazardous areas on the morning of 4/20/11 it was noted that the doors to the paint shop and the HVAC repair shops were not fire rated. In addition, the door to both rooms was provided with a grill that would allow passage of smoke through the tunnel system in the event of fire. Hospital areas and non-hospital areas of the tunnel system were not separated by rated doors.

2. The doors, to the electrical closet in the corridor of the outpatient clinic on "A" level, were not fire rated.
.

Based on observation and interview the facility did not ensure that emergency lighting was provided as required.

Findings:

1. During a tour of the South stair exit discharge on the morning of 4/2/11 it was noted that exterior lighting tied to emergency power, of at least 1 & 1/2 hours duration, was not provided.

2. 30 day functional tests and annual 1 & 1/2 hour annual testing of the battery powered emergency lights in the South exit stair and the generator transfer switch room were not conducted.
Interview with staff # 2 stated that that the emergency lighting in the South stair is not tested because it is redundant i.e., other lighting is provided tied into the emergency generator. The NFPA requires that existing life safety features obvious to the public shall be either maintained or removed.
NFPA 101 2000 7.9.3
NFPA 101 2000 4.6.12.2

3. During a tour of the procedure rooms on the afternoon of 4/19/11 it was noted that a 90 minute Battery-Powered Emergency Lighting Unit, with a lighting level sufficient to terminate procedures, was not provided in each of the procedure rooms.
NFPA 99 1999 3-3.2.1.2(5)(e).
.

Based on document review and interview the facility did not provide a written plan for the protection of all patients in the event of emergency.

Findings:

1. During review of the hospital's fire safety plans it was noted that there was no site specific fire plan for the endoscopy suite. There was no assessment of the hazards found in the procedure rooms e.g., an enriched oxygen atmosphere, use of electrical surgical units and use of endotracheal tubing. This was confirmed in interview with staff # 1
NFPA 99 1999 12-4.1.2.10


2. The facility's fire plan does not provide for the use of a code phrase to ensure alarm transmission under the following conditions:

a. When the individual who discovers a fire must immediately go to the aid of an endangered person
b. During a malfunction of the building fire alarm system.
.

Based on document review and interview the facility did not ensure that all staff are familiar with fire safety procedures:

Finding

Review of fire safety drills on the afternoon of 4/19/11 revealed that no site specific in-service training of staff or fire drills for the endoscopy suite have taken place at any time. This was confirmed in interview with Staff # 1
NFPA 99 1999 12-4.1.2.10
.

Based on record review and interview the hospital did not ensure that all components of the fire alarm (FA ) were maintained in accordance with NFPA 72.

Findings:

1. Documentation was provided to show that dampers on the 3rd floor inpatient unit were tested but no documentation was available to show that dampers on level A and the first floor were tested. This information was requested on 4/19/11 and again on 4/20/11 from staff members but was not provided.

2. It could not be determined if all components of the FA system that require testing were, in fact, tested because records do not include the number of devices that must be tested. The report from the FA vendor includes a blanket statement that all devices were tested but does not include the number or location of said devices.
NFPA 72 1999 Chapter 7 Inspection, Testing, and Maintenance
.

Based on observation and record review the facility did not ensure that the sprinkler system is maintained in accordance with NFPA 25 Table 5.1

Findings:

1 On the morning of 4/18/11 it was noted that 18" clearance was not provided for sprinkler heads in the storage room on Level A adjacent to the nurses station. Sprinkler head coverage was blocked by a box containing a Christmas tree and by boxes containing print cartridges.

2. Review of maintenance records on the afternoon on 4/19/11 revealed that the annual main drain test was not performed as required. Records of April 2011 show from that a fire pump test with water running was performed but not a main drain test recording static pressure, residual pressures and water flow (gallons per minute GPM ). Request for hydraulic name plate information showing residual pressure was requested but not provided. Main drain testing documentation for previous years was available.

3. No documentation was available to show that show that the 5 year internal inspections for obstructions were conducted on sprinkler piping, check valves, alarm devices and associated trim.
.

Based on observation and interview the hospital did not ensure that medical gas storage is protected as required.

Finding:

During a tour of the 3rd floor procedure suite on the morning of 4/20/11 it was noted that the Oxygen Manifold room was not protected. The room lacked a one hour rated separation and self-closing door. The light switch was located at height of approximately of 40" off the floor rather than the required 5 feet. In addition, entrance to the Oxygen Manifold Room was through the patient recovery area.
.

Based on document review and and interview the facility did not ensure that elevators conform to the requirements of ASME / ANSI A17.3

Finding:

On the afternoon of 4/19/11 elevator maintenance and testing records dated 10/12/10 for elevator devices, IP3198, IP7713, IP7714, and IP43023 were reviewed. The inspection reports identified as unsatisfactory for some components of these devices. The surveyor requested that Staff # 2 provide the Affidavit of Correction, required to be submitted to the NYC Department of Buildings upon correction of deficiencies, however the affidavit was not available. A second request was made on the morning of 4/20/11 but the requested documentation was not provided.
.