HospitalInspections.org

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

The inspector observed, while accompanied by The CEO and The Safety Officer during the hours of the inspection from 10AM to 12 PM on 05/20/2015 that there was the following issues:

A.)There was missing fire rated sealant/ caulking missing at the above ceiling of the fire rate and smoke barrier partitions.
B) While performing the fire alarm testing the cross corridor door located at the smoke barrier partition were not fully closed.

Based on observation the facility failed to provide adequate fire protection.

The inspector observed, while accompanied by The Safety Officer during the hours of the inspection from 10AM to 12 PM on 05/20/2015 that there was the following issues:


A.) There were door stop wedge located at the Stairwell fire rated door. Please remove the door stop.

" Fire doors shall be self-closing or automatic-closing. " - NFPA 101, 2003: 8.3.3.3 & 7.2.1.8.

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

The inspector observed, while accompanied by The Safety Officer during the hours of the inspection from 10AM to 12 PM on 05/20/2015 that there was the following issues:


A.) The facility failed to provide signage at the Medical Gas Storage Room door. Provide the following signage:

Re. NFPA 99, 2002: 5.1.3.1.5. The door shall have the following label:

CAUTION
Medical Gases
NO Smoking or Open Flame
B.) There were no individual chains for the medical gases bottles.

" 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.

The inspector observed, while accompanied by The CEO and The Safety Officer during the hours of the inspection from 10AM to 12 PM on 05/20/2015 that there was the following issues:



A) The annual Generator system testing was unclear about the Load test specified for the annual test per NFPA 110:8-4.2 and NFPA 110:8-4.8 and full load test an d the transfer switch and circuit break testing.
B) Fire Alarm semi-annually and annual system testing log was not adequate.
C) The Grounding system testing at inpatient areas on TDSHS form were not performed.
D) The filter change Log was not adequate.

The inspector observed, while accompanied by The CEO and The Safety Officer during the hours of the inspection from 10AM to 12 PM on 05/20/2015 that there was the following issues:

A.) At the essential transfer switch location. There was a missing task illumination (battery powered light fixture)
B.) The flexible conduits were utilized for the essential electrical panels - life safety and critical panels. Please provide hard conduits.


" 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 transfer switch location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

" The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable, " - NFPA 70, 2002, 517.30 (C)(3).

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

The inspector observed, while accompanied by The CEO and The Safety Officer during the hours of the inspection from 10AM to 12 PM on 05/20/2015 that there was the following issues:

A.)There was missing fire rated sealant/ caulking missing at the above ceiling of the fire rate and smoke barrier partitions.
B) While performing the fire alarm testing the cross corridor door located at the smoke barrier partition were not fully closed.

Based on observation the facility failed to provide adequate fire protection.

The inspector observed, while accompanied by The Safety Officer during the hours of the inspection from 10AM to 12 PM on 05/20/2015 that there was the following issues:


A.) There were door stop wedge located at the Stairwell fire rated door. Please remove the door stop.

" Fire doors shall be self-closing or automatic-closing. " - NFPA 101, 2003: 8.3.3.3 & 7.2.1.8.

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

The inspector observed, while accompanied by The Safety Officer during the hours of the inspection from 10AM to 12 PM on 05/20/2015 that there was the following issues:


A.) The facility failed to provide signage at the Medical Gas Storage Room door. Provide the following signage:

Re. NFPA 99, 2002: 5.1.3.1.5. The door shall have the following label:

CAUTION
Medical Gases
NO Smoking or Open Flame
B.) There were no individual chains for the medical gases bottles.

" 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.

The inspector observed, while accompanied by The CEO and The Safety Officer during the hours of the inspection from 10AM to 12 PM on 05/20/2015 that there was the following issues:



A) The annual Generator system testing was unclear about the Load test specified for the annual test per NFPA 110:8-4.2 and NFPA 110:8-4.8 and full load test an d the transfer switch and circuit break testing.
B) Fire Alarm semi-annually and annual system testing log was not adequate.
C) The Grounding system testing at inpatient areas on TDSHS form were not performed.
D) The filter change Log was not adequate.

The inspector observed, while accompanied by The CEO and The Safety Officer during the hours of the inspection from 10AM to 12 PM on 05/20/2015 that there was the following issues:

A.) At the essential transfer switch location. There was a missing task illumination (battery powered light fixture)
B.) The flexible conduits were utilized for the essential electrical panels - life safety and critical panels. Please provide hard conduits.


" 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 transfer switch location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

" The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable, " - NFPA 70, 2002, 517.30 (C)(3).