HospitalInspections.org

Based on observations made during the survey of the facility between the hours of 2:00 pm and 6:00 pm, while accompanied by the CEO/Administrator, and Maintenance Manager it was observed that the facility failed to maintain the required fire/smoke rating for a portion of the SMOKE BARRIER WALL. There were multiple unsealed penetrations located in this wall above the cross-corridor doors near Room Numbers 109 and 110. It appeared that multiple penetrations were sealed with expansive thermal foam product which is highly flammable.

Based on observations made during the survey of the facility between the hours of 2:00 pm and 6:00 pm, while accompanied by the CEO/Administrator, and Maintenance Manager it was observed that the facility failed to provide a log indicating compliance with requirement for monthly testing by staff of the fire alarm system and its automatic signal response.

Based on observations made during the survey of the facility between the hours of 2:00 pm and 6:00 pm, while accompanied by the CEO/Administrator, and Maintenance Manager it was observed that the facility failed to provide the following requirements:

1. MAINTAIN MINIMUM 8 FEET IN WIDTH FOR HOSPITAL EGRESS CORRIDORS - The required minimum 8 feet in width for all Hospital Egress/ Patient Corridors was violated in a non-compliant section of the Egress/Patient Corridor located immediately outside of the main entrance into the O.R. Surgery Suite. This section of the Egress/Patient Corridor had been reduced down to only 6 feet in width. This section of non-compliant (6 foot wide) Hospital Egress/Patient Corridor was approximately 10 feet long.

Additionally, this non-compliant section of the Hospital Egress/Patient Corridor lies within a longer section of Hospital Egress/Patient Corridor which was constructed on a zig-zag layout (multiple 90 degree turns), and upon leaving the O.R. Surgery Suite you are at one of those 90 degree turns in the Hospital Egress/Patient Corridor. As you go through the doors to leave Surgery, and make an immediate left turn you encounter the start of the 6 foot wide Hospital Egress/Patient Corridor which then continues the reduced width for about 10 feet in length. However, in addition to navigating the turn, not only has the corridor narrowed, but a non-compliant 48 inch wide cased opening has also been constructed through which patient/ bed/ staff must also navigate.

Finally, just beyond the other end of the non-compliant section of corridor is a cross-corridor, double-egress door and frame (7 feet, 4 inches wide) which has been installed in a "compliant section" which has the required 8 foot wide Hospital Egress/Patient Corridor. So on one side of this cross-corridor door there is enough corridor width to have installed the double-egress door assembly; and on the other side of the door there is not adequate corridor width to see the entire width of the cross-corridor door assembly - much less use it as intended.
This is in violation of Code Regulations as well as Hospital Licensing Rules.

All of the following (described above) must be corrected and brought into compliance:
A. The 6 foot wide section of Hospital Egress Corridor must be corrected and restored back to 8 feet in width.
B. The 48 inch wide cased opening must be entirely removed leaving the Hospital Egress/ Patient Corridor to it's full required width of 8 feet.
C. There must be 8 feet clear on either side of the cross-corridor, double-egress door assembly to allow unencumbered access to the full clear width of this door opening regardless of which direction of travel.

Resolution for K-130-1 A, B & C shall include the following as regards the LSC / RE-SURVEY Plan Of Correction requirements:
A. Include a written Plan Of Correction response for K-130-1 A, B & C.
(in the same manner as you would for other K-tags).
B. Within the Plan Of Correction response for K-130-1 A, B & C provide a statement indicating that the facility will submit this as a planned " new construction project " with TDSHS
1. Complete with submittal of signed and sealed Construction Drawings and Specifications from an MEP Engineer licensed in the State of Texas.
2. Additionally, a program narrative and fees are required to be submitted to TDSHS at which time TDSHS will review the submittal and assign a " Project Application Number " for the project.
C. Also within the Plan Of Correction response for K-130-1 A, B & C provide " estimated time frames" : 1. For when the engineered "project design" will be started and completed.
2. For when the contractor "project construction" will be started and completed.

2. PERMANENT LABELING OF ESSENTIAL ELECTRICAL SERVICE (EES) PANELS - There were two ATS devices that were not identified on the face of the device with label, color coded to readily identify the emergency transfer switch device. Emergency transfer switch device shall be distinctively marked to make it readily identifiable as a component of the essential electrical system. They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.
NFPA 70, 2002: 700.9(A) " All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system. "

NFPA 70, 2002: 110-22

3. In the MED GAS STORAGE area there was an electrical light switch device in the wall located less than 60 inches above finish floor level. This is not in compliance with the requirements of NFPA 99 HEALTH CARE FACILITIES.

4. REQUIRED CONTINUOUS LOW EXHAUST FOR MED GAS STORAGE - The MED GAS STORAGE ROOM did not have the required continuous low exhaust. This is not in compliance with the following:
NFPA 99, 2002: 5.1.3.3.3.1(B) " Where the total volume of medical gases connected and in storage is greater than 3,000 cu.ft. at STP, indoor supply locations shall be provided with dedicated mechanical ventilation systems that draw air from within 1 foot of the floor and operate continuously. "

NFPA 99, 2002: 5.1.3.3.1(D). " Where the total volume of medical gases connected and in storage is less than 3000 cu.ft. at STP, natural ventilation shall be permitted

NFPA 99, 2002: 5.1.3.3.3.1(E) " Where natural ventilation is permitted, it shall consist of two louvered openings, each having a minimum free area of 72 in. sq., with one located within 1 ft. of the floor and one located within 1 ft. of the ceiling. "

Based on observations made during the survey of the facility between the hours of 2:00 pm and 6:00 pm, while accompanied by the CEO/Administrator, and Maintenance Manager it was observed that the facility failed to provide an Emergency Generator log indicating consistent, systematic compliance on the following issues and items:

1. Weekly inspections.

Based on observations made during the survey of the facility between the hours of 2:00 pm and 6:00 pm, while accompanied by the CEO/Administrator, and Maintenance Manager it was observed that the facility failed to maintain the required fire/smoke rating for a portion of the SMOKE BARRIER WALL. There were multiple unsealed penetrations located in this wall above the cross-corridor doors near Room Numbers 109 and 110. It appeared that multiple penetrations were sealed with expansive thermal foam product which is highly flammable.

Based on observations made during the survey of the facility between the hours of 2:00 pm and 6:00 pm, while accompanied by the CEO/Administrator, and Maintenance Manager it was observed that the facility failed to provide a log indicating compliance with requirement for monthly testing by staff of the fire alarm system and its automatic signal response.

Based on observations made during the survey of the facility between the hours of 2:00 pm and 6:00 pm, while accompanied by the CEO/Administrator, and Maintenance Manager it was observed that the facility failed to provide the following requirements:

1. MAINTAIN MINIMUM 8 FEET IN WIDTH FOR HOSPITAL EGRESS CORRIDORS - The required minimum 8 feet in width for all Hospital Egress/ Patient Corridors was violated in a non-compliant section of the Egress/Patient Corridor located immediately outside of the main entrance into the O.R. Surgery Suite. This section of the Egress/Patient Corridor had been reduced down to only 6 feet in width. This section of non-compliant (6 foot wide) Hospital Egress/Patient Corridor was approximately 10 feet long.

Additionally, this non-compliant section of the Hospital Egress/Patient Corridor lies within a longer section of Hospital Egress/Patient Corridor which was constructed on a zig-zag layout (multiple 90 degree turns), and upon leaving the O.R. Surgery Suite you are at one of those 90 degree turns in the Hospital Egress/Patient Corridor. As you go through the doors to leave Surgery, and make an immediate left turn you encounter the start of the 6 foot wide Hospital Egress/Patient Corridor which then continues the reduced width for about 10 feet in length. However, in addition to navigating the turn, not only has the corridor narrowed, but a non-compliant 48 inch wide cased opening has also been constructed through which patient/ bed/ staff must also navigate.

Finally, just beyond the other end of the non-compliant section of corridor is a cross-corridor, double-egress door and frame (7 feet, 4 inches wide) which has been installed in a "compliant section" which has the required 8 foot wide Hospital Egress/Patient Corridor. So on one side of this cross-corridor door there is enough corridor width to have installed the double-egress door assembly; and on the other side of the door there is not adequate corridor width to see the entire width of the cross-corridor door assembly - much less use it as intended.
This is in violation of Code Regulations as well as Hospital Licensing Rules.

All of the following (described above) must be corrected and brought into compliance:
A. The 6 foot wide section of Hospital Egress Corridor must be corrected and restored back to 8 feet in width.
B. The 48 inch wide cased opening must be entirely removed leaving the Hospital Egress/ Patient Corridor to it's full required width of 8 feet.
C. There must be 8 feet clear on either side of the cross-corridor, double-egress door assembly to allow unencumbered access to the full clear width of this door opening regardless of which direction of travel.

Resolution for K-130-1 A, B & C shall include the following as regards the LSC / RE-SURVEY Plan Of Correction requirements:
A. Include a written Plan Of Correction response for K-130-1 A, B & C.
(in the same manner as you would for other K-tags).
B. Within the Plan Of Correction response for K-130-1 A, B & C provide a statement indicating that the facility will submit this as a planned " new construction project " with TDSHS
1. Complete with submittal of signed and sealed Construction Drawings and Specifications from an MEP Engineer licensed in the State of Texas.
2. Additionally, a program narrative and fees are required to be submitted to TDSHS at which time TDSHS will review the submittal and assign a " Project Application Number " for the project.
C. Also within the Plan Of Correction response for K-130-1 A, B & C provide " estimated time frames" : 1. For when the engineered "project design" will be started and completed.
2. For when the contractor "project construction" will be started and completed.

2. PERMANENT LABELING OF ESSENTIAL ELECTRICAL SERVICE (EES) PANELS - There were two ATS devices that were not identified on the face of the device with label, color coded to readily identify the emergency transfer switch device. Emergency transfer switch device shall be distinctively marked to make it readily identifiable as a component of the essential electrical system. They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.
NFPA 70, 2002: 700.9(A) " All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system. "

NFPA 70, 2002: 110-22

3. In the MED GAS STORAGE area there was an electrical light switch device in the wall located less than 60 inches above finish floor level. This is not in compliance with the requirements of NFPA 99 HEALTH CARE FACILITIES.

4. REQUIRED CONTINUOUS LOW EXHAUST FOR MED GAS STORAGE - The MED GAS STORAGE ROOM did not have the required continuous low exhaust. This is not in compliance with the following:
NFPA 99, 2002: 5.1.3.3.3.1(B) " Where the total volume of medical gases connected and in storage is greater than 3,000 cu.ft. at STP, indoor supply locations shall be provided with dedicated mechanical ventilation systems that draw air from within 1 foot of the floor and operate continuously. "

NFPA 99, 2002: 5.1.3.3.1(D). " Where the total volume of medical gases connected and in storage is less than 3000 cu.ft. at STP, natural ventilation shall be permitted

NFPA 99, 2002: 5.1.3.3.3.1(E) " Where natural ventilation is permitted, it shall consist of two louvered openings, each having a minimum free area of 72 in. sq., with one located within 1 ft. of the floor and one located within 1 ft. of the ceiling. "

Based on observations made during the survey of the facility between the hours of 2:00 pm and 6:00 pm, while accompanied by the CEO/Administrator, and Maintenance Manager it was observed that the facility failed to provide an Emergency Generator log indicating consistent, systematic compliance on the following issues and items:

1. Weekly inspections.