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Based on document review and staff interview, the facility did not ensure that the fire drills were conducted under varying conditions and that planning /evaluation of fire drills were done as per NFPA 101.


Findings include:


1. A review of the fire drill record on 11/07/14 at 11:45 AM indicated that the facility has instituted a checklist highlighting the points of the drill on which the staff conducting the drill/observer checks off "yes" or "no".


The fire drill records were reviewed on 11/7/14. It was revealed that the hospital staff did not conduct fire drills that include 'simulation of various types of emergency fire conditions. There was no evidence that the staff ensured that each staff has a full and clear understanding of the facility's fire safety plan, or how to execute it successfully under the varying conditions.


The fire drills checklist and report did not indicate under what scenario the fire drill was initiated. The fire drill checklist and report did not include a detailed critique of all the responses of staff observed during the drill.


The findings were brought to the attention of the Director of Security on 11/07/14 at 11:45 AM.

Based on observations, it was determined that the facility did not ensure that all sprinkler pipes are free of any foreign material and paints as per NFPA 25 and NFPA 13, Standard for the Inspection, Testing and Maintenance of Water Based Fire and Protection System.


Findings include:


During the tour of the Laundry area located in the basement of the building on 11/04/14 at 12:30 PM, it was observed that the exposed sprinkler heads and pipes in the room exhibited an accumulation of lint, dust and dirt.


Note: Section 2-2.1.1* of NFPA 25 states that, "Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation."


During the tour these findings were observed and verified with the Director of Engineering, the Director of Infection Control and the Vice President of Support Services.

Based on record review and staff interview, the facility did not ensure that the areas with medical gas outlet were tested. Also, there was no evidence that inaccessible outlets were tested as per NFPA 99.



Findings include:


On 11/06/14 at 12:00 PM, a review of the medical gas report of the facility from 'Praxair' dated 04/16/14, indicated that room #s 6 and 9 in ICU 3rd floor did not have their outlet for oxygen tested because they were unavailable. Room #6 also did not have its medical air outlet tested. There was no evidence to indicate that the outlets in these two rooms were tested at a later time to ensure its operation.


The Director of Engineering provided a report on 11/07/14 at 11:30 AM that indicated that the vendor was called in the evening of 11/06/14 (after the issue was brought to the facility's attention) to have the outlets tested and the outlets passed their test.


There was no evidence that the above mentioned outlets were checked from 04/16/14 to the morning of 11/06/14. This indicated that the facility did not check the medical gas system in an effective and timely manner.


These findings were confirmed with the Director of Engineering, and the Vice President of Support Services during a review of the report.

Based on observation, document review and staff interview, the facility did not ensure that the TYPE 1 Essential Electrical System (EES) wiring for three branches of Emergency Generator was done as per NFPA 99 3.4.2.2.2 and thus did not ensure that anything that is not required to be wired to Life Safety is accurately wired to either Critical Branch of Equipment Branch.


Findings include:


On 11/3/14 at 12:00 PM, during the tour of the 5th floor of the facility, the Directory of Engineer was questioned regarding the location of the emergency electrical panels.


A panel board labeled "EC5N' located in the corridor was told to be an emergency branch panel feed from panel 00342. There was no label or verification of which branch of the emergency generator is serving this panel.


In reviewing the directory it was noted that there was wiring for the receptacles on the panel along with lighting of vestibule and unit heaters. The emergency generator's electrical panels were opened to review what items were wired in those panels. If this was considered a Life Safety Branch panel (because it had vestibule lighting) then it had a mixing of wiring with Critical Care Branch (which is for receptacles in a patient rooms) and Equipment Branch (for the heaters).


Therefore, it was concluded that this panel has mixed wiring and is not wired as per TYPE 1 EES. The Director of Engineering stated that this panel is coming off the 'ATS-6' automatic transfer switch which the facility has identified to be non-compliant and which the facility is working to separate the wiring.


The issue of ATS-6 having mixed load of the three branches of TYPE 1 EES is a REPEAT DEFICIENCY FROM THE FEDERAL SURVEY OF 11/08/13. The facility was cited for the same issue and had responded in its Plan of Correction that "Facility Staff had previously identified this issue and had hired an engineer to develop a plan of correction. Electrical engineer will design and develop the plan and corrective action to separate ATS #6 from the Life Safety, Critical and Equipment branches. Because of the complexity of the Electrical distribution system, this plan is extensive and will require a minimum of 6 to 10 months to correct. Local municipality permitting will be required. Responsible party: Vice President of Facilities". Completion date (for the issue cited) in the column of X5 date was provided as 10/1/14.


The Director of Engineering (DOE) was not aware that the completion date, as indicated in the facility's Plan of Correction for the 11/08/13 Survey, for the same issue has passed. As per the Director of Engineering the purchase order was just recently processed and the work for the installation and separation will require a few months for its completion.


A purchase requisition dated 10/29/14 was provided to the surveyor on 11/05/14. The Director of Engineering indicated an anticipated date of completion by December 2014 for the project of ATS #6. However, there were no formal time line with policy and procedure to ensure adherence to the anticipated completion date for the project.


2. A purchase order from last year dated 11/7/2013 to "Batska Engineering" was also provided. This document stated "Implement recommended actions from the ATS condition study prepared by this office on 09/28/13 on behalf of New York Presbyterian Hospital in order to make the facility compliant with requirements of NFPA 99. According to the study, ATS -6 (600A) appears to be the only automatic transfer switch on the Lawrence Hospital Campus that does not serve a segregated load. The scope will include removing the life safety and critical branch loads from this ATS, and connect them to ATS-9-LS and ATS-7-CR respectively".


During the survey of the facility from 11/04/14 to 11/5/14 between 11:00 AM to 3:00 PM, two more electrical panels were noted having mixed wiring. The panels were in the Central Sterilization Processing room EM/DP #1 LBS and in the Emergency Department EC1S-2. Director of Engineering stated that he could not verify that these two panels were being served from ATS #6, and he does not know which ATS switches are serving these panels and if they and other ATS switches are also mixed.


Therefore, the issue of 'Repeat Deficiency' is not confined to the ATS #6 currently having mixed wiring and not separated for three branches. The issue also includes the mixed wiring present in other panels supplied by other ATS that have not been evaluated to ensure compliance with NFPA 99 codes, which requires having three separate branches on ALL electrical panels present in the facility. All documents and Director of Engineering interviews indicated facility's focus of remediation of ATS #6 only.


All above findings were verified with Vice President of Support Services and Director of Engineering.


999 NFPA 99 3-4.2.1.4, 3-4.2.2, NFPA 70: Article 517 and Article 700.

Note: As per NFPA 99 Section 3-4.2.2.2
(b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101, ® Life Safety Code®
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems."
4. Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.

NOTE: No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.

1. Based on document review and staff interview, facility did not ensure that the electrical safety test was conducted on the patient care instruments as per frequency defined by NFPA 99.

Findings include:


On 11/07/14 at 11:00 AM facility was requested to provide information for the critical and non-critical patient care equipment. As per the Director of Bio-med the electrical checks are done as a part and frequency of preventive maintenance prescribed for the equipment. It was observed during document review that the facility has "LTV1200" ventilators that have their preventive maintenance once a year. The Director of Bio-Med acknowledged that no electrical safety test was in any other time of the year since it is a part of the preventive maintenance. Thus the LTV1200 ventilators got their electrical safety check annually.


A ventilator is considered a critical or life support equipment and therefore as per NFPA 99 the frequency of electrical safety check should be bi-annually. There was no documented justification available/provided based on previous results that may allow the ventilator to have only an annual electrical safety check.


Note: NFPA 99 Section 7-6.2.1.2 Testing Intervals states:


"a) the facility shall establish policies and protocols for the type of test and intervals of testing for each appliance.


b) All appliances used in patient care areas shall be tested in accordance with 7-5.1.3 or 7-5.2.2.1 before being put into service for the first time and after repair or modification. Patient-care-related electrical appliances shall be retested at intervals determined by their normal location or area of normal use, but not exceeding the intervals listed below:


General Care Areas - 12 Months
Critical Care Areas - 6 Months
Wet Locations - 6 Months


Exception No. 1: The testing intervals listed are intended to be nominal values, and facilities shall be permitted to adopt a protocol using either longer or shorter intervals provided that there is a documented justification based on previous safety testing records for the equipment in question, unusually light or heavy utilization, or similar considerations."


Findings were verified with the Director of Bio-Med and Vice President of Support Services.



2. Based on staff interview and document review all electrical receptacles in patient care areas were not tested and maintained as per code.


Findings include:


On 11/06/14 at 3:30 PM, the Director of Engineering was requested to provide evidence that electrical receptacles in the patient care areas were tested.


The facility also did not have any policy and procedure or statistics in place regarding the frequency the test should be conducted periodically if not annually. The facility needs to determine the frequency of testing by evidence based data and ensure that servicing of the electrical receptacles is done as per NFPA 99 so that all receptacles are operational with no electrical leakage or any other problem.


NOTE: NFPA 1999 (99 ed) section 3-3.4.2.3 Maintenance and Testing of Electrical system Testing Interval for Receptacles in Patient Care Areas states that:


"(1) Testing shall be performed after initial installation, replacement, or servicing of the device.


(2) Additional Testing shall be performed at intervals defined by documented performance data."


Findings were verified with the Director of Engineering and the Vice President of Support Services.


3. Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was installed in accordance with NFPA 13 1999 [Standard for the Installation of Sprinkler Systems], to provide complete coverage in the fully sprinklered Tower Building.


Findings include:


On 11/04/14 at 1:30 PM during the tour of the Critical Care Unit on 3rd floor it was noted that, the electrical closet and the supplies closet located close to the electrical closet did not have any sprinkler head. The suite as per floor plan is fully sprinklered.


It is to be noted that NFPA 13, section 5-13.1.1* states that:
"All concealed spaces enclosed wholly or partly by exposed combustible construction shall be protected by sprinklers".


Closets are part of the building structure, which have the walls, ceiling, and floor generally made of the same construction materials as the building. Closets are required to be sprinklered to be considered fully sprinklered.


Findings were observed and verified with Vice President of Support Services and Director of Engineering.


4. Based on observation and staff interview, the facility did not ensure that the electrical rooms are protected by either a sprinkler head or two hour wall as per NFPA 13 1999.


Findings include:


During inspection of the electrical closet on 3rd floor outside Critical Care Unit on 11/04/14 at 1:45 PM it was noted that there was no sprinkler head in the closet. As per the floor plan this room is not indicated to be rated having two hour fire wall / protection.


NFPA 13 1999 Section 5-13.11 states that:


"Sprinkler protection shall be required in electrical equipment rooms. Hoods or shields installed to protect important electrical equipment from sprinkler discharge shall be noncombustible.

Exception: Sprinklers shall not be required where all of the following conditions are met
(a) The room is dedicated to electrical equipment only.
(b) Only dry-type electrical equipment is used.
(c) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations.
d) No combustible storage is permitted to be stored in the room."

Findings were verified with Director of Engineering and Vice President of Support Services.

5. Based on observation, facility did not ensure that the electrical panels on the floor and in the main electrical room are identified for the circuits served by emergency power system and specifically the branch it serves.


Findings include:


During the survey of the facility from 11/03/14 to 11/05/14 between 10:30 AM to 4:00 PM, observations of all electrical panels on different floors and in the main switch gear room in the basement, it was observed that none of the electrical panels were conspicuously identified/labeled for the circuits served by emergency power system and the branches. The distributions were not identified on the panel circuit directory.

NFPA 70 section 384-13 states that:
"All panel board circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors".

Findings were verified with the Vice President of Support Services, and the Director of Engineering,


6. Based on observation and staff interview, the facility could not verify that all patient bed locations have emergency power which is marked with a distinct color to identify the presence of emergency power.


Findings include:


On 11/04/14 at 2:00 PM, during the tour of the 3rd floor on 3 north it was noted that in room #310 there were no red/emergency receptacles. One regular duplex receptacle by the patient bed was labeled with a white label indicating that it was the emergency receptacle.


The Director of Engineering was asked to provide verification and information regarding which branch of emergency system is supplying this specific receptacle. The Director of Engineering did not provide information for this receptacle.


NFPA 70 section 517-18. States:
"(a) Patient Bed Location. Each patient bed location shall be supplied by at least two branch circuits, one from the emergency system and one from the normal system. All branch circuits from the normal system shall originate in the same panel board".


Since all receptacles on TYPE 1 EES are supposed to be fed from Critical branch, therefor the code further states:
NFPA 70 section 517-33x(c) Receptacle Identification.
"The receptacles or the faceplates for receptacles supplied by the critical branch shall have a distinctive color or marking so as to be readily recognizable."


Above findings were verified with the Vice President of Support Services and the Director of Engineering.

Based on staff interview, the facility did not ensure that the elevators that have or require fire fighter Phase I and Phase II recall were tested as per code requirement.

Findings include:

On 11/7/14 at 2:00 PM a request was made to the Director of Engineering for a report regarding the recall feature of all of the elevators. The fire alarm report stated that all elevators are equipped with fire fighter service Phase I and Phase II.

The Director of Engineering acknowledged that there were no written reports of monthly inspections or of periodic testing of this fire fighter service system.