Table of Contents
St Marys Hospital for Children Inc
Deficiency Details, Certification Survey, July 8, 2011
PFI: 1665
Regional Office: MARO--New York City Area
K53 NFPA 101, 483.70(a)(7): AUTOMATIC SMOKE DETECTION SYSTEM
Scope: Isolated
Severity: Potential for more than Minimal Harm
Corrected Date: August 4, 2011
In an existing nursing home, not fully sprinklered, the resident sleeping rooms and public areas (dining rooms, activity rooms, resident meeting rooms, etc) are to be equipped with single station battery-operated smoke detectors. There will be a testing, maintenance and battery replacement program to ensure proper operation. 42 CFR 483.70(a)(7)
Citation date: July 8, 2011
Based on observation and interview it was determined that the facility did not ensure that all areas used by children were protected at the minimum, with single-station, battery operated smoke detectors. This was evidenced by the lack of smoke detectors in rooms 421 and 300. The building is partially sprinklered.
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
The findings are:
On 07/05/11 between thee hours of 7:30 am and 12:00 pm, various rooms (421,300) that were used by children were not installed with any fire protection device (smoke detector or sprinkler).
In an interview with the director of facilties at approximately 9:00 am he stated that a smoke detector will be installed.
42 CFR 483.71(a)(1)
NYCRR 415.29
K38 NFPA 101: EXIT ACCESS
Scope: Isolated
Severity: Potential for more than Minimal Harm
Corrected Date: August 4, 2011
Exit access is arranged so that exits are readily accessible at all times in accordance with section 7.1. 19.2.1
Citation date: July 8, 2011
Based on the observation, and interview it was determined that the facility did not ensure that a continuous and unobstructed way of travel from the basement was maintained as evidenced by exit door that was difficult to open and exit path obstructed with bushes and weeds.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
The Findings are:
On 07/05/11 during the Annual Life Safety evaluation it was observed that the ground floor "G3" stairway "4" exit door to the public way was not readily opened. The amount of force needed to open the door was greater than 15 lbf (67N A staff member was asked to open the door and after trying to open the door she stated "can't open". Also,the exit path to public way from this G3 exit door was not kept clear as evidenced by weeds and bushes.
In an interview with the maintenance director on 07/05/11 at approximately 12:00 pm, he stated that the stairway and door was painted recently and as it dried might have caused the door to stick to the frame. He stated that he will immediately correct the above stated concerns. In a faxed report to the office on 7/06/11, he stated that all the above concerns were corrected.
LSC NFPA 101-2000 edition, 19.2.1 NYCRR 711.2(a)(1)
K18 NFPA 101: CORRIDOR DOORS
Scope: Pattern
Severity: Potential for no more than Minimal Harm
Corrected Date: Not Available
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3 Roller latches are prohibited by CMS regulations in all health care facilities.
Citation date: July 8, 2011
The following requirement of The Life Safety Code has been previously waived. Repeat waivers are granted based on previous jsutifications by the owner, previous NYSDOH and USDHHS reviews and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver to be continued.
Include in your request for renewal of this waiver or plan of correction in the space provided on this form.
K18, S/S=B
Patient's rooms are not provided with doors.
NFPA 101 - 2000: 19.3.6.2
NYCRR 711.2(a)(1)