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Observation and discussion with the facility representatives between 8:30 am and 6 pm on 9/27/2011 revealed that certain requirements stipulated in NFPA 72 were not met.

Fire Alarm Control Panel

Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and service shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit [Re: NFPA 72, National Fire Alarm Code, 1999: ? 1-5.2.5.2.]

Findings: The FACP, located in S442 which is an electrical room behind a janitor ' s closet, did not meet this requirement. The facility shall ensure that this requirement is met with the main FACP and all booster panels as well. [Surveyor 18604.]

a. Fan Operation

Based on observations made during the tour of the facility on the morning and afternoon 0f 09/27/2011 with the engineering administrator, the safety officer, and a quality management RN the facility failed to assure that the heating ventilating and air conditioning system was in full compliance with NFPA 90A.

Findings: The return air fan component of the air handling units serving the third through the eighth floors of the north and south tower did not automatically shut down on activation of either the return air or supply air duct mounted smoke detectors serving the respective units. [Surveyor 06169.]

b. Proper Pressure Relationships

Observation and discussion with the facility representatives between 8:30 am and 6 pm on 9/27/2011 revealed that certain requirements stipulated in the State Hospital Licensing Rooms were not met.

All areas within the hospital must satisfy the relationships specified in Table 3, Figure 25 TAC ?133.169[c], Ventilation Requirements for Hospitals and Outpatient Clinics, [Re: 25 TAC, HLR, 2007: 133.162(d)(3)(D)(i).]

Findings: The proper relationships were not found at several locations, including the Janitor ' s Closet, ST175, and Patient to Ante Room relationship in the 4th Floor PICU. [Surveyor 18604.]

a. Biomed Equipment

Based on observations made during the tour of the facility on the afternoon of 09/27/2011 with the engineering administrator, the director of the neonatal CCU, and a quality management RN, the facility failed to assure that the biomedical equipment serving critical care areas was being tested at intervals complying with the requirements NFPA 99: 7-6.2.1.2.

Findings:

(1) The IV Infusion pumps in the neonatal ICU on the 3rd floor of the north tower were being tested annually instead of semi-annually.

(2) The physiological monitors in the neonatal ICU on the 3rd floor of the north tower were being tested annually instead of semi-annually. [Surveyor 06169.]

b. Nurse Call System

Observation and discussion with the facility representatives between 8:30 am and 6 pm on 9/27/2011 revealed that certain requirements stipulated in the State Hospital Licensing Rules were not met.

A staff emergency assistance calling system [Code Blue] is intended to be used by staff to summon additional help in an emergency. ... ...Calls shall activate audible and visible signals in accordance with Table 7 of ?133.169(g) of this title. .... [Re: 25 TAC HLR, 2007: ?133.162(d)(5)(L)(iii).]

Findings: A typical nurse call system was not installed in the surgical suite [OR#2] and in the PACU. A staff person must utilize a PC to initiate calls which is not acceptable. A nurse call station was also not installed in the ante room of the seclusion room, 2nd floor of Bldg 11. [Surveyor 18604.]

a. Lighting

Based on observations made on the afternoon of 09/27/2011 with the engineering administrator, the director of the neonatal ICU, and a quality management RN, the facility failed to assure that the Type I essential electrical was in compliance with NFPA 99: 3-4.2.2.2.

Findings:

(1) The neonatal ICU suite on the 3rd floor did not have emergency lighting in the passageways.

(2) The critical care patient rooms on the second floor did not have task illumination on emergency power. ][Surveyor 06169.]

b. Functional Allocation

Observation and discussion with the facility representatives between 8:30 am and 6 pm on 9/27/2011 revealed that certain electrical installations for the Type I essential electrical was not in compliance with NFPA 99: 3-4.2.2.2.

Specific requirements exist identifying the functions as they must be allocated to the critical branch [NFPA 70, National Electrical Code, 2002, ?517.33], life safety branch [NFPA 70, National Electrical Code, 2002, ?517.32], and the equipment system [NFPA 70, National Electrical Code, 2002, ?517.34].

Findings: During the survey, it was noted that the loads circuited by panelboards in the 2nd, 3rd, and 4th floor electrical rooms did not meet the requirements. The facility shall ensure that only the proper loads are circuited from the appropriate panelboards. [Surveyor 18604.]

c. Component Labels

All boxes and enclosures (including transfer switches, transformers, distribution panels, and panelboards) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system [Re: NFPA 70, NEC, 2002: 700.9(A).]

Findings: The above listed components shall be labeled with the words " CRITICAL BRANCH " , " LIFE SAFETY BRANCH " or " EQUIPMENT BRANCH " to be readily identifiable as part of the Essential Electrical System. [Surveyor 18604.]

d. Circuit Directory

All 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 door in the case of a panelboard, and at each switch on a switchboard [Re: NFPA 70, National Electrical Code, 2002: ? 408.4.]

Findings: All circuit directories must be updated to be legible and meaningful. [Surveyor 18604.]

Based on observations made on the afternoon of 09/27/2011 with the engineering administrator, the director of the CCU, and a quality management RN, the facility failed to assure that the Type I essential electrical was in compliance with NFPA 70: 57-19(a).

Findings: The emergency receptacles at the patient headwalls in the critical care patient rooms on the 2nd floor did not have permanent labeling identifying the paneboard and circuit numbers supplying power to them. [Surveyor 06169.]

Observation and discussion with the facility representatives between 8:30 am and 6 pm on 9/27/2011 revealed that certain requirements stipulated in NFPA 72 were not met.

Fire Alarm Control Panel

Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and service shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit [Re: NFPA 72, National Fire Alarm Code, 1999: ? 1-5.2.5.2.]

Findings: The FACP, located in S442 which is an electrical room behind a janitor ' s closet, did not meet this requirement. The facility shall ensure that this requirement is met with the main FACP and all booster panels as well. [Surveyor 18604.]

a. Fan Operation

Based on observations made during the tour of the facility on the morning and afternoon 0f 09/27/2011 with the engineering administrator, the safety officer, and a quality management RN the facility failed to assure that the heating ventilating and air conditioning system was in full compliance with NFPA 90A.

Findings: The return air fan component of the air handling units serving the third through the eighth floors of the north and south tower did not automatically shut down on activation of either the return air or supply air duct mounted smoke detectors serving the respective units. [Surveyor 06169.]

b. Proper Pressure Relationships

Observation and discussion with the facility representatives between 8:30 am and 6 pm on 9/27/2011 revealed that certain requirements stipulated in the State Hospital Licensing Rooms were not met.

All areas within the hospital must satisfy the relationships specified in Table 3, Figure 25 TAC ?133.169[c], Ventilation Requirements for Hospitals and Outpatient Clinics, [Re: 25 TAC, HLR, 2007: 133.162(d)(3)(D)(i).]

Findings: The proper relationships were not found at several locations, including the Janitor ' s Closet, ST175, and Patient to Ante Room relationship in the 4th Floor PICU. [Surveyor 18604.]

a. Biomed Equipment

Based on observations made during the tour of the facility on the afternoon of 09/27/2011 with the engineering administrator, the director of the neonatal CCU, and a quality management RN, the facility failed to assure that the biomedical equipment serving critical care areas was being tested at intervals complying with the requirements NFPA 99: 7-6.2.1.2.

Findings:

(1) The IV Infusion pumps in the neonatal ICU on the 3rd floor of the north tower were being tested annually instead of semi-annually.

(2) The physiological monitors in the neonatal ICU on the 3rd floor of the north tower were being tested annually instead of semi-annually. [Surveyor 06169.]

b. Nurse Call System

Observation and discussion with the facility representatives between 8:30 am and 6 pm on 9/27/2011 revealed that certain requirements stipulated in the State Hospital Licensing Rules were not met.

A staff emergency assistance calling system [Code Blue] is intended to be used by staff to summon additional help in an emergency. ... ...Calls shall activate audible and visible signals in accordance with Table 7 of ?133.169(g) of this title. .... [Re: 25 TAC HLR, 2007: ?133.162(d)(5)(L)(iii).]

Findings: A typical nurse call system was not installed in the surgical suite [OR#2] and in the PACU. A staff person must utilize a PC to initiate calls which is not acceptable. A nurse call station was also not installed in the ante room of the seclusion room, 2nd floor of Bldg 11. [Surveyor 18604.]

a. Lighting

Based on observations made on the afternoon of 09/27/2011 with the engineering administrator, the director of the neonatal ICU, and a quality management RN, the facility failed to assure that the Type I essential electrical was in compliance with NFPA 99: 3-4.2.2.2.

Findings:

(1) The neonatal ICU suite on the 3rd floor did not have emergency lighting in the passageways.

(2) The critical care patient rooms on the second floor did not have task illumination on emergency power. ][Surveyor 06169.]

b. Functional Allocation

Observation and discussion with the facility representatives between 8:30 am and 6 pm on 9/27/2011 revealed that certain electrical installations for the Type I essential electrical was not in compliance with NFPA 99: 3-4.2.2.2.

Specific requirements exist identifying the functions as they must be allocated to the critical branch [NFPA 70, National Electrical Code, 2002, ?517.33], life safety branch [NFPA 70, National Electrical Code, 2002, ?517.32], and the equipment system [NFPA 70, National Electrical Code, 2002, ?517.34].

Findings: During the survey, it was noted that the loads circuited by panelboards in the 2nd, 3rd, and 4th floor electrical rooms did not meet the requirements. The facility shall ensure that only the proper loads are circuited from the appropriate panelboards. [Surveyor 18604.]

c. Component Labels

All boxes and enclosures (including transfer switches, transformers, distribution panels, and panelboards) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system [Re: NFPA 70, NEC, 2002: 700.9(A).]

Findings: The above listed components shall be labeled with the words " CRITICAL BRANCH " , " LIFE SAFETY BRANCH " or " EQUIPMENT BRANCH " to be readily identifiable as part of the Essential Electrical System. [Surveyor 18604.]

d. Circuit Directory

All 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 door in the case of a panelboard, and at each switch on a switchboard [Re: NFPA 70, National Electrical Code, 2002: ? 408.4.]

Findings: All circuit directories must be updated to be legible and meaningful. [Surveyor 18604.]

Based on observations made on the afternoon of 09/27/2011 with the engineering administrator, the director of the CCU, and a quality management RN, the facility failed to assure that the Type I essential electrical was in compliance with NFPA 70: 57-19(a).

Findings: The emergency receptacles at the patient headwalls in the critical care patient rooms on the 2nd floor did not have permanent labeling identifying the paneboard and circuit numbers supplying power to them. [Surveyor 06169.]