HospitalInspections.org

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the director of the safety during the hours of the inspection from 2:30 pm to 4:00 pm on 12/10/2013 that there were penetrations not sealed in the fire rated partitions at the following locations: 1) ceiling above the smoke barrier cross corridor doors at the first floor and the second floor.

Based on observation the facility failed to provide adequate medical gas system.

The inspector observed, while accompanied by the director of the safety during the hours of the inspection from 2:30 pm to 4:00 pm on 12/10/2013 that there were the following issues:


A.) Based on observation the facility failed to provide individual chains for the medical gases bottles. This does not comply with the following NFPA code. " Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. " - NFPA 99, 1999: 4-3.1.1.1.

B.) There was no signage provided at the Med Gas storage door.

CAUTION
Medical Gases
NO Smoking or Open Flame

See NFPA 99, 2002: 5.1.3.1.6.

Based on observation the facility failed to provide adequate receptacles and battery powered lighting units.

The inspector observed, while accompanied by the director of the safety during the hours of the inspection from 2:30 pm to 4:00 pm on 12/10/2013 that there were the following issues.

(1). There was a missing battery powered lighting units at the generator set location. (2). There was a missing battery powered lighting units and a missing receptacle powered from life safety branch at the generator set location. (2). FACP breaker was not provided in red breaker and labeled in red signage permanently. (3) There were three electrical panels in the electrical room that was not labeled or identified as " Life Safety " , " Equipment " and " critical " . (4) the electrical directory was not updated.

" The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location and essential automatic transfer switch location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

" NFPA 72, 2002: 4.4.1.4.2.2 -The electrical connection between the panel/breaker and the FACP must be cross referenced correctly. " The circuit breaker at the electrical panel board for the fire alarm shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as "FIRE ALARM CIRCUIT CONTROL" " - NFPA 72, 2002: 4.4.1.4.2.2. " The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit. " - NFPA 72, 2002: 4.4.1.4.2.3 "

Based on observation the facility failed to provide the Grounding system report for inpatient care areas and the Line Isolation Monitor Tests report on TDSHS form. This is required of all hospitals.

The inspector observed, while accompanied by Hospital CEO, Director of the facility, director of the safety, and director of purchasing during the hours of the inspection from 2:30 pm to 4:00 pm on 12/10/2013 that there were the following issues.

A) The facility failed to provide a history of records for receptacle testing at inpatient care areas and the Line Isolation Monitor per NFPA 99: 3-3.3.3. in patient care areas.

" Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). "

" NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, ?133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984). "

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the director of the safety during the hours of the inspection from 2:30 pm to 4:00 pm on 12/10/2013 that there were penetrations not sealed in the fire rated partitions at the following locations: 1) ceiling above the smoke barrier cross corridor doors at the first floor and the second floor.

Based on observation the facility failed to provide adequate medical gas system.

The inspector observed, while accompanied by the director of the safety during the hours of the inspection from 2:30 pm to 4:00 pm on 12/10/2013 that there were the following issues:


A.) Based on observation the facility failed to provide individual chains for the medical gases bottles. This does not comply with the following NFPA code. " Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. " - NFPA 99, 1999: 4-3.1.1.1.

B.) There was no signage provided at the Med Gas storage door.

CAUTION
Medical Gases
NO Smoking or Open Flame

See NFPA 99, 2002: 5.1.3.1.6.

Based on observation the facility failed to provide adequate receptacles and battery powered lighting units.

The inspector observed, while accompanied by the director of the safety during the hours of the inspection from 2:30 pm to 4:00 pm on 12/10/2013 that there were the following issues.

(1). There was a missing battery powered lighting units at the generator set location. (2). There was a missing battery powered lighting units and a missing receptacle powered from life safety branch at the generator set location. (2). FACP breaker was not provided in red breaker and labeled in red signage permanently. (3) There were three electrical panels in the electrical room that was not labeled or identified as " Life Safety " , " Equipment " and " critical " . (4) the electrical directory was not updated.

" The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location and essential automatic transfer switch location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

" NFPA 72, 2002: 4.4.1.4.2.2 -The electrical connection between the panel/breaker and the FACP must be cross referenced correctly. " The circuit breaker at the electrical panel board for the fire alarm shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as "FIRE ALARM CIRCUIT CONTROL" " - NFPA 72, 2002: 4.4.1.4.2.2. " The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit. " - NFPA 72, 2002: 4.4.1.4.2.3 "

Based on observation the facility failed to provide the Grounding system report for inpatient care areas and the Line Isolation Monitor Tests report on TDSHS form. This is required of all hospitals.

The inspector observed, while accompanied by Hospital CEO, Director of the facility, director of the safety, and director of purchasing during the hours of the inspection from 2:30 pm to 4:00 pm on 12/10/2013 that there were the following issues.

A) The facility failed to provide a history of records for receptacle testing at inpatient care areas and the Line Isolation Monitor per NFPA 99: 3-3.3.3. in patient care areas.

" Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). "

" NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, ?133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984). "