HospitalInspections.org

Based on a walk-through of the facility on 04/12/2022, it was observed that 13 licensed patient bedrooms are being used as storage room, offices, and the entire ICU department has been turned into a physical rehab patient care unit and office area.

An application package is required for any person, facility or corporation modifying or erecting the physical plant for the following types of healthcare facilities, which are regulated by the Health and Human Services Commission, Architectural Review Unit (ARU). Application Instruction Policy ARU-21 from website.

TAC 25, Chapter 133,
§133.26 (b)(1) The fee for an initial license or a renewal license is $39 per bed based upon the design bed capacity of the hospital. The design bed capacity of a hospital is determined as follows.

§133.26 (b)(1)(A) The design bed capacity is the maximum number of patient beds that a hospital can accommodate in rooms that comply with the requirements for patient room suites in §133.163 of this title (relating to Spatial Requirements for New Construction) including beds, bassinets or cribs in critical care units (including neonatal nurseries), continuing care nursery beds, hospital-based skilled nursing units, medical nursing units, mental health and chemical dependency nursing units, pediatric and adolescent nursing units, obstetrical suites (including labor/delivery/recovery/postpartum (LDRP) beds), intermediate care beds, universal care beds, antepartum beds and postpartum beds. The design bed capacity does not include labor/delivery/recovery (LDR) beds, newborn nursery bassinets, or recovery beds.
§133.26 (a)(1) (B) The maximum design bed capacity includes beds that comply with the requirements in §133.163 of this title even if the beds are unoccupied or the space is used for other purposes such as offices or storage rooms, provided such rooms can readily be returned to patient use. All required support and service areas must be maintained in place. For example, the removal of a nurse station in an unused patient bedroom wing of 20 beds would effectively eliminate those 20 beds from the design capacity. Eliminating access to the medical gas outlets and nurse call would also remove bed(s) from the design capacity.
§133.161 (a)(2) (D) Major remodeling or alterations. Plans shall be submitted in accordance with §133.167 of this title for all major remodeling or alterations. All remodeling or alterations which involve alterations to load bearing members or partitions, change functional operation, affect fire safety (e.g. modifications to the fire, smoke, and corridor walls), or add beds or services over those for which the hospital is licensed are considered as major remodeling and alterations.
§133.161 (a)(2)(D) Major remodeling or alterations. Plans shall be submitted in accordance with §133.167 of this title for all major remodeling or alterations. All remodeling or alterations which involve alterations to load bearing members or partitions, change functional operation, affect fire safety (e.g. modifications to the fire, smoke, and corridor walls), or add beds or services over those for which the hospital is licensed are considered as major remodeling and alterations.





Based on a walk-through of the facility on 04/12/2022, it was observed that IV prep machines were out of service and located in a staff breakroom. The hospital can eithr get the out-of-service IV prep machines repaired or if they are abdoned removed from the site. If the machines are being held for repair, they should be located in the biomed room and tagged for repair. The IV prep machines should then be repaired and logged back into the system if the hospital decided to keep the machines. For either of the two options, equipment should not be stored in the staff break room.




Based on a walk-through of the facility on 04/12/2022, it was observed the drug narcotics room is not labeled. This room can be labeled storage, but it does need to be labeled. Also, the drug narcotics room was not secured.





Based on a walk-through of the facility on 04/12/2022, nurse call (emergency pull chord) was tested in the patient care bedroom's bathroom and it appears it was not registering correctly at the nurse station annunciator panel. When the nurse call pull cord is activated in patient rooms 202 and 203 it shows up at the receiving station as a normal function. Please verify that the emergency pull chord signals to the medical staff at both the dome light in the corridor, outside the patient bedroom and the nurse station's annunciator that the patient needs emergency assistance Please explain what happens when the pull chord is activated in bathroom 202 and 203.

Based on a walk-through of the facility on 04/12/2022, it was observed that several exit lights were not operational in the hospital.

Based on a walk-through of the facility on 04/12/2022, it was observed the fire alarm panel is missing its blue annual inspection tag for the year 2021.

Based on a walk-through of the facility on 04/12/2022, it was observed that 3 fire sprinkler heads are corroded in the dish washer room.





Based on an observation made of the paperwork provided during the survey on 04/12/2022 it was noted that the facility is not testing the fire sprinkler system at the correct intervals. The facility is missing 3 quarterly fire sprinkler inspections from 2019, 2020 and 2021.

Based on a walk-through of the facility on 04/12/2022, the patient restrooms in bedrooms 210,213,211,209,207,205,203 are not negatively pressurized. Exhaust shall be continuously operational.

ASHRAE Table 7.1
TAC 25, Chapter 133, Table 3

§133.163 (t)(3)(B) Each patient room bathroom shall be exhausted continuously to the exterior in accordance with Table 3 of §133.169(c) of this title.

Based on a walk-through of the facility on 04/12/2022, it was observed that the patient curtains in room 202,204 and 208 do not provide the NFPA 701- Flame Retardant tag.

Based on a walk-through of the facility on 04/12/2022, it was observed that the facility does not have a kill switch for the generator on the hospital property.

Based on an observation made of the paperwork provided during the survey on 04/12/2022 it was noted that the facility is not performing the required annual receptacle testing.