HospitalInspections.org

Based on observation and interview, it was determined that the facility did not ensure that all doors opening onto and protecting the corridors from fire/smoke in the patient treatment area, were kept free of impediments to ensure positive latching and quick closing of the doors in case of an emergency.

Findings include:

1. During observations of the facility from 04/19/10 to 04/23/10, it was noted that the rooms opening into the common exit corridor were kept open by inserting plastic wedges underneath the edges. The plastic wedges will impede the prompt closure of door in case of fire. When brought to their attention during the tour, the facility staff removed them.
Examples, including but not limited to, are:
a. The kitchen/pantry door in the Sleep Center (3rd floor-Spellman) was held open by a wedge inserted beneath the door.
b. The door to the Hyperbaric Chamber room was held open by a plastic wedge inserted beneath the door. This situation is not only impeding the prompt closure of the door but also compromising the 2 hour rating of the room for any fire emergency in the Hyperbaric Chamber room that may extend to the corridor.
c. The Radiology suite's doors, opening to the corridor, were propped open by placing a foot stand or other items in front of the door or stuck beneath the edge of the door.
d. Patient room doors on the 5th floor-Cooke were noted to have a dust bin placed in the doorway in such a manner that prompt closure of the door may not occur.

2. All findings were verified with Staff #2 and Staff #34 at the time of the observations.

NFPA 101 (2000 edition) 19.2.1, 19.3.6.3, (19.3.6.3.6), 7.2.

Based on observation, the facility did not ensure that all hazardous areas are safeguarded from other spaces, by smoke/fire rated partitions, doors which are self-closing or automatic-closing, and/or are provided with the positive latching devices to protect from fire/smoke, as detailed in 19.3.2.1.

The findings include:

1. During observations of the main Central Clean Linen storage/laundry on 04/23/10 at 1:45 PM (1st floor Thorne), it was noted that the room was not sprinklered and was separated from an adjacent storage room (labeled as SPD) with construction, whose 1 hour fire rating could not be verified at the time of survey. The wall separating the SPD room had a plastic window and facility staff did not know if the window had any rating.
Furthermore, it could not be verified if a wall of sheetrock at the back of the Clean Linen storage room, and separating the room from the adjacent area, had a 1 hour rating.

2. Similarly, the SPD storage room had an abundant amount of combustible material and the door from the Clean Linen storage room to the SPD storage room was not positively latched/completely shut, which compromised the 1 hour rating. This situation may lead to the quick spread of fire from the SPD room to the Clean Linen storage/laundry, if any combustible material in SPD caught fire.

The walls and ceiling of both rooms exhibited gross disrepair, which may also contribute to the spread of fire and compromise the integrity of the fire-rated construction.

3. During observations of the facility from 04/19/10 to 04/23/10, it was noted that multiple environmental/janitors' closets in the facility did not have a self-closure installed at the door. Examples, including but not limited to, are:
a. The janitor's closet in front of OR2, did not have a self-closure at the door.
b. The janitor's closet on Med/Surg Unit, 6th floor-Cooke, did not have a self-closure at the door.
c. The janitor's closet on PCU/ICU, 3rd floor-Cooke, did not have a self-closure at the door.

4. On 04/23/10 at 11:45 AM it was noted that the door of the soiled utility room in the Cardiac Cath lab/suite did not latch positively.

LSC NFPA 101, 19.3.2.1, 8.3.6,
All the above findings were shared with and brought to the attention of staff accompanying the surveyor at the time. (Staff #2 and Staff #34).

Based on observation, it was determined that the facility did not ensure that the door to the first floor gift shop (more than 500 square feet) where hazardous quantities of combustibles are stored, is not kept open to the corridor.

Findings include:

1. On 04/22/10 at 12:15 PM, and 04/23/10 at 3:00 PM, it was observed that the gift shop, located in the lobby area, is used for storage of hazardous quantities of stuffed toys and other combustible materials. The gift shop area is 978 Square feet and is provided with an automatic extinguishing system (sprinkler system). However, the door to the gift shop area was open to the corridor/lobby area and therefore was not positively latched. The door is provided with a self-closure but that self-closure did not shut the door and kept the door open.

It is to be noted that as per NFPA 101 19.2.2.2.6 and 7.2.1.8.2, any door in a hazardous area shall be permitted to be held open ONLY by devices arranged to automatically close all doors in case of fire alarm activation and other scenarios as described in the code.

2. Findings were verified with Staff #2 and Staff #34 at the time of observation.

Based on record review and interview, the hospital did not ensure that the fire alarm system is maintained in accordance with NFPA 72.

Findings include

On 03/23/10 at 2:30 PM, during document review of the fire alarm test reports, Staff #2 was requested to indicate/provide the reports for the sensitivity test of the smoke detectors. Staff #2 was unsure where to find the specific information in the reports, and called the vendor. The vendor was unaware of this requirement. Therefore, based on feedback by Staff #2, the facility did not have the sensitivity test reports for all the smoke detectors as required by NFPA 72, 7-3.2.1.

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."

Based on observation it was determined that the facility failed to maintain sprinkler heads free from foreign particles in all parts of the facility as required by NFPA 25.

Findings include:

1. On 04/20/10 at 2:45 PM, during observations of the Central Sterile Supply room, it was noted that 3 sprinkler heads in the room were heavily covered with dust and dirt.

2. On 04/22/10 at 11:30 AM, during observations of the PCU/ICU on 3rd floor-Cooke, the sprinkler head in the environmental/janitorial closet exhibited heavy accumulation of dust and dirt.

3. On 04/23/10 at 12:15 PM, during observations of the Hyperbaric/wound center on the 2nd floor-Spellman, it was noted that a sprinkler head in the Communication closet had paint on it.

All findings were verified with Staff #2 and Staff #34 at the time of observation.

Based on observation, it was determined that the facility failed to ensure that all portable fire extinguishers are installed conspicuously and that the top of the fire extinguisher is not more than 5 feet (60 inches) above the floor (see reference NFPA 10, 1-6.10).

Findings include:

1. During observations on 04/20/10 at 11:00 AM of the Mechanical room on the 7th floor-Cooke, it was noted that a portable fire extinguisher was installed on the wall with its topmost portion at 65 inches above the floor.

2. A similar finding was observed on 04/23/10 at 12:00 PM in the storage room of the lab where the extinguisher was installed with its topmost portion between 65-68 inches above the floor.

Findings were verified with Staff #2 and Staff #34 at the time of observation.

Based on observation and staff interview, it was determined that the facility did not maintain the piped in medical gas system as per NFPA 99.

Findings include:

1. During observations of the facility from 04/19/10 to 04/23/10 between 10:30AM to 3:30 PM, it was noted that the oxygen pressure reading on the main medical gas alarm panel in the Operating Room, Endoscopy and Emergency Department, was reading 49 PSI. This situation was brought to the attention of Staff #2. It is to be noted that as per NFPA 99, Table 4-3.1.2.4, the standard pressure to be maintained for oxygen delivery, is 50 PSI (+5/-0).

2. On 04/22/10 at 3:00 PM during observations, staff interview and documentation review in the Hyperbaric/Wound Center, it was noted that, chamber startup logs indicated that the Oxygen pressure was being recorded as 47 PSI-49 PSI on some days. As per the manufacturer's recommendation and manual as specified in section 2.2 & 2.1, oxygen should be delivered at a minimum of 50 PSI. The site-specific checklist/log asks staff to record the oxygen supply pressure at the valve. However, it was noted that during the week of 04/19/10, the form was modified and included a printed alarm range of 45-70PSI. Staff #22 stated that hospital management had included this range and she was not aware of the reason. There was no policy available to indicate why the manufacture's guidelines would be by-passed by the facility, what were the cut off/alarm point of the oxygen or what, if any, are the side effects of not delivering oxygen at the required pressure, (especially in the hyperbaric chamber).

3. Findings were shared with Staff #2, Staff #34, and Staff #22 at the times of the observations.

Section 8.3.6.1of NFPA 101 states that:
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:

(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:

a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.

Based on observation, it was determined that the facility did not ensure that penetrations of fire/smoke barrier walls were protected/sealed with a material capable of maintaining the smoke resistance of the barrier as per NFPA 101, 2000, 8.3.6

Findings include:

1. During observations of the facility between 04/19/10 to 04/22/10, the fire/smoke barriers above the drop ceiling of the double doors were inspected regarding the integrity of smoke barriers. It was noted that the smoke barrier by Med/Surg Unit, 6th & 5th floor-Cooke, and Rehab Unit, 4th floor-Cooke were penetrated by ducts, pipes, conduits, cables, wires for interior illuminating lights installed during renovation of floor electrical/information technology work. None of the penetrations were sealed completely with an approved fire retardant material to prevent passage of smoke from one compartment to the other.

2. It was noted that the inside of the corridor wall/smoke barrier of the mechanical room, on 1st floor-Cooke, exhibited penetration by a 3 inch electrical conduit.
Similarly, it was noted that a steam pipe was penetrating the fire/smoke barrier above the double door leading to the Radiology suite and was missing the fire retardant.
A green conduit was found penetrating the fire/smoke wall in the gift shop, without fire retardant.

All findings were verified with Staff #2 and Staff #34 at the time of observations.

A- Section 8-3.1.11.2 of NFPA 99 states:
Storage for nonflammable gases less than 3000 ft. 3 (85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft. (6.1 m), or
2. A minimum distance of 5 ft. (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
(d) Liquefied gas container storage shall comply with 4-3.1.1.2(b)4.
(e) Cylinder and container storage locations shall meet 4-3.1.1.2(a)11e with respect to temperature limitations.
(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.
(g) Cylinder protection from mechanical shock shall meet 4-3.5.2.1(b)13.
(h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.
(i) Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20 ft. (6.1 m) of outside storage locations.
(j) Cylinder valve protection caps shall meet 4-3.5.2.1(b)14.

Based on observation, it was determined that the facility did not ensure that oxygen cylinders on patient floors were stored as per the requirement mentioned above in NFPA 99.

Findings include:

a. During the tour of the Rehab/Joint Replacement Center (4th floor-Cooke) on 04/21/10 at 4:00PM, it was noted that nine E class oxygen cylinders were stored inside a sprinklered clean utility room, shared by both Rehab and the Total Joint Departments. The clean utility room was not secured for unauthorized entry (as per 8-3.1.11.2.a).

b. The above-referenced clean utility room had an abundant supply of combustible materials such as boxes, alcohol-based hand sanitizers, plastic wraps/supplies and other materials. The oxygen tanks were kept on racks which were not placed in a manner to ensure at least 5 feet distance away from the combustibles.

c. A similar finding was noted on 3rd floor-Cooke in the PCU/ICU, where nine E class oxygen cylinders were placed adjacent to the rack, housing gloves, boxes, alcohol hand sanitizers and other combustible material. This clean utility room was also not secured from unauthorized access.

Findings were verified with Staff #2 and Staff #34 at the time of observations.

B- Section 8-3.1.11.3 of NFPA 25 states:
A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum: CAUTION, OXIDIZING GAS(ES) STORED WITHIN, NO SMOKING.

Based on observation, it was determined that the facility did not post any precautionary sign outside the main oxygen/medical gas cylinder storage room on 1st floor-Thorne.

Findings include:

During an observation on 04/23/10 at 1:41 PM, it was noted that the main storage room for the portable oxygen tanks/medical gas cylinder on 1st floor-Thorne, did not have a precautionary sign installed on the door. It is important for the staff and other people to be aware that the room contains an abundant amount of oxygen so that they may avoid bringing into or nearby the premises any electrical equipment/item that may cause or catch fire.

Finding was verified with Staff #2 and Staff #34 at the time of observations.

Based on document review, it was noted that the facility did not ensure that all the existing elevators serving the patient care areas are certified to have firefighter recall feature installed.

Findings include:

During staff interview and fire alarm documentation review on 04/21/10 at 10:30 AM, it was revealed that 2 banks of Thorne elevators and 1 bank of Roosevelt elevators did not have the firefighter feature installed.

Finding was shared with Staff #2 at the time of observations.