HospitalInspections.org

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Regarding B E N T A U B H O S P I T A L

Based on observations made during the survey of the facility between the hours of 2:00 PM to 6:00 PM on 9/24/2019 and 8:30 am to 1:00 PM on 9/25/2019 , while accompanied by the Administration Director, VP Operations, EVP Administration, Sr. VP Corporate Compliance and Admin. Director of Compliance, it was observed that the facility was not in compliance with the following:

The Level 1 and Level 2 "LIFE SAFETY FLOOR PLAN" drawings incorrectly show a 1-hour fire-rating where there are OCCUPANCY SEPARATION WALLS. The CODE requires these OCCUPANCY SEPARATION WALLS to be 2-hour fire-rated at this change in occupancy between the Licensed Hospital portion of the "Tower" building and the Non-Hospital Licensed portions of the "Neuropsychiatric Center" building.

Not having this information shown correctly in these "LIFE SAFETY FLOOR PLAN" drawings is not acceptable for a Licensed Hospital. Hospitals need accurate fire-rating information for multiple reasons: SAFETY of patients, TRAINING of staff, MAINTAINING INTEGRITY of rated construction, and REGULATORY REVIEW of their facility.

Additionally, the surveyor was tasked to view drawings which do not quickly, & clearly indicate adjacency relationships of the multiple buildings which comprise the entirety of the campus' buildings. Neither do current drawing quickly and clearly indicate where the boundaries are between the Non-Hospital Licensed portions of the building and the Licensed Hospital. It was discussed on-site that there could be a clearer and quicker way to "SEE AT A GLANCE" just where these distinctions occur. Having a single drawing showing all of the various buildings and how they are situated - adjacent to one another would also be a big help. The above will not only help Regulatory Inspections, but should also be just as helpful to members of the Stake Holder's community who work to utilize and maintain this facility.

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Regarding L B J H O S P I T A L

The surveyor observed, while accompanied by the Program Director, Vice President Operator, Facility management Director, and the Engineer Director, during the hours of the inspection from 09:30 PM to 05:30 PM on 09/25/2019 and the morning of 09/26/2019, on the 2nd floor and the third floor, some of the fire/smoke rated double egress doors were not released from the magnetic hold open device upon activation of the fire alarm system. Please verify all other mag lock of the entire facility are released for free egress upon the fire alarm activation.

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Regarding L B J H O S P I T A L

The surveyor observed, while accompanied by the Program Director, Vice President Operator, Facility management Director, and the Engineer Director, during the hours of the inspection from 09:30 PM to 05:30 PM on 09/25/2019 and the morning of 09/26/2019, the following issues:

A) Some of the smoke barrier cross corridor doors on 2nd floor, 3rd floor, and the 4th floor were not fully closed upon the fire alarm activation. Please verify all other smoke barrier cross corridor doors of the entire facility are fully closed upon the fire alarm activation.

B) Some of the smoke barrier partition were not fire caulked.

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Regarding B E N T A U B H O S P I T A L

Ducts Protection

Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide, such as ducts, decks, open grate flooring, cutting tables, and overhead doors. NFPA, 2010:8.6.5.3.3

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

The surveyor observed, while accompanied by the Director of Engineering, Engineering Supervisor, Quality Control Technician, and Administration Assistant, during the hours of the inspection from 2:00 PM to 6:00 PM on 9/24/2019 and 8:30 am to 1:00 PM on 9/25/2019 that in the NPC building Penthouse, there was an area under a duct that was not covered or protected by the single sprinkler head. Add an extra sprinkler head to fully cover/protect all the areas under the duct.

Firestops:

"Firestop Systems and Devices Required. Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through- Penetration Firestops, at a minimum positive pressure differential of 0.01 in. water column (2.5 N/m 2 between the exposed and the unexposed surface of the test assembly." NFPA 101, 2012, 8.3.5.1*


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

The surveyor observed, while accompanied by the Director of Engineering, Engineering Supervisor, Quality Control Technician, and Administration Assistant, during the hours of the inspection from 2:00 PM to 6:00 PM on 9/24/2019 and 8:30 am to 1:00 PM on 9/25/2019 that:

1. In the Switch Gear room (fire rated electrical room) there were many penetration holes on the wall that were not properly caulked with firestop system.

2. In the Medical gas room (bottles storage) there walls repair that were incorrectly performed. Remove the scabs and patch the wall correctly.

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Regarding B E N T A U B H O S P I T A L

Final filters and Frames:

Final filters and filter frames should be visually inspected for pressure drop and for bypass monthly. Filters should be replaced based on pressure drop or maintenance schedule with filters that provide the efficiencies specified. (ASHRAE 170, Informative Appendix A, Operations and Maintenance Procedures.) A log of filter replacements should be maintained for each air handler.


Based on observation the facility failed to provide adequate monthly pressure drop records.

The surveyor observed, while accompanied by the Director of Engineering, Engineering Supervisor, Quality Control Technician, and Administration Assistant, during the hours of the inspection from 2:00 PM to 6:00 PM on 9/24/2019 and 8:30 am to 1:00 PM on 9/25/2019 that there was no record or logs of each air handler showing dates when the final filters, pre-filters have been replaced with the pressure differential across the filter before and after replacement where differential pressure monitors are required.

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Regarding B E N T A U B H O S P I T A L

PURPLE ELEVATOR GROUP comprised of 3 elevators identified as: ELEV. 2, ELEV. 3, and ELEV. 4.

Prior to testing the PURPLE ELEVATOR GROUP - ELEV. 4 appeared to function properly until all three elevator cabs were placed into test mode. During the test mode ELEV. 4 was rendered unresponsive. This elevator was unresponsive to the ELEVATOR CONTROLS, and was also unresponsive to the FIRE ALARM SYSTEM during the extended testing period.

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Regarding B E N T A U B H O S P I T A L

Based on observation, the facility failed to provide a risk assessment for the medical gas system.

The surveyor observed, while accompanied by the Director of Engineering, Engineering Supervisor, Quality Control Technician, and Administration Assistant, during the hours of the inspection from 2:00 pm to 6:00 pm on 9/24/2019 and 8:30 am to 1:00pm on 9/25/2019 that the facility had not done a risk assessment to determine the procedures and schedule for testing the medical gas system.

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R E G A R D I N G : B E N T A U B

Labeling of Transfer Switches and Panels:

"Identification. 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, 2011, 700.10. They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.

Based on observation, the facility failed to provide adequate essential electrical system.

The surveyor observed, while accompanied by the Director of Engineering, Engineering Supervisor, Quality Control Technician, and Administration Assistant, during the hours of the inspection from 2:00 PM to 6:00 PM on 9/24/2019 and 8:30 am to 1:00 PM on 9/25/2019 that across board all the Essential Electrical System panels were not labeled Life Safety, Critical, and Equipment panels accordance with the code. The Ben Taub proprietary labeling system on the panels do not meet the requirement of the code.

Panel directory:

"Circuit Directory or Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panel board and located at each switch or circuit breaker in a switchboard. No circuit shall be described in a manner that depends on transient conditions of occupancy." - NFPA 70, 2011, 408.4 (A) Note: Labeling includes all disconnecting means, see 110.22.


Based on observation, the facility failed to provide adequate Essential Electrical System (EES).

The surveyor observed, while accompanied by the Director of Engineering, Engineering Supervisor, Quality Control Technician, and Administration Assistant, during the hours of the inspection from 2:00 PM to 6:00 PM on 9/24/2019 and 8:30 am to 1:00 PM on 9/25/2019 that many EES Life Safety and Critical panels directories were difficult to read. Panel directories shall be legible.


FACP Marking:

"The location of the dedicated branch circuit disconnecting means shall be permanently identified at the control unit." - NFPA 72, 2010, 10.5.5.2.1.

"For fire alarm systems the circuit disconnecting means shall have a red marking." - NFPA 72, 2010, 10.5.5.2.3.


Based on observation, the facility failed to provide adequate marking on the breaker supplying power to the FACP.

The surveyor observed, while accompanied by the Director of Engineering, Engineering Supervisor, Quality Control Technician, and Administration Assistant, during the hours of the inspection from 2:00 PM to 6:00 PM on 9/24/2019 and 8:30 am to 1:00 PM on 9/25/2019 that:

1. FACP in room 1.349 NPC building referenced Critical panel address as the location of the breaker-LVCR-12. FACP breaker shall be on life safety panel and shall be painted "Red".

2. In Room HCHD 4.123, the Life safety panel the breaker supplying power to the FACP was not painted red.

3. In the 2nd floor NPC building -MHMDA Electrical room, the FACP breaker was not painted red.


Essential Electrical System Segregation (Life Safety):

"The essential electrical system shall be divided into the following three branches: (1) Life safety, (2) Critical, (3) Equipment." NFPA 99, 2012, 6.4.2.2.1.1.

6.4.2.2.3 Life Safety Branch.
6.4.2.2.3.1 The life safety branch shall be limited to circuits essential to life safety.

6.4.2.2.3.2 "The life safety branch shall supply power for lighting, receptacles, and equipment as follows:

(1) Illumination of means of egress in accordance with 101, Life Safety Code,

(2) Exit signs and exit directional signs in accordance with NFPA 101, Life Safety Code,

(3) Hospital communications systems, where used for issuing instruction during emergency conditions,

(4) Generator set locations as follows:

(a) Task illumination,

(b) Battery charger for emergency battery-powered lighting unit(s),

(c) Select receptacles at the generator set location and essential electrical system transfer switch locations,

(5) Elevator cab lighting, control, communications, and signal systems,

(6) Electrically powered doors used for building egress,

(7) Fire alarms and auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm and Signaling Code."


6.4.2.2.3.3 "Alarm and alerting systems (other than fire alarm systems) shall be connected to the life safety branch or critical branch."


6.4.2.2.3.4 "Loads dedicated to a specific generator, including the fuel transfer pump(s), ventilation fans, electrically operated louvers, controls, cooling system, and other generator accessories essential for generator operation, shall be connected to the life safety branch or the output terminals of the generator with overcurrent protective devices."


6.4.2.2.3.5 "No functions other than those in 6.4.2.2.3.2, 6.4.2.2.3.3, and 6.4.2.2.3.4 shall be connected to the life safety branch, except as specifically permitted in 6.4.2.2.3."


Based on observation, the facility had incorrect circuits connected in the essential electrical system.

The surveyor observed, while accompanied by the Director of Engineering, Engineering Supervisor, Quality Control Technician, and Administration Assistant, during the hours of the inspection from 2:00 PM to 6:00 PM on 9/24/2019 and 8:30 am to 1:00 PM on 9/25/2019 that:

1. The select receptacles in the ATS locations could not be verified to be connected to life safety panel.

2. They were circuit breakers on the life safety panels were supposed to be on equipment panel. Verify that the breakers on the life safety panel are the required circuits and move all other circuits to either critical or equipment panels.


Essential Electrical System Segregation (Critical):

6.4.2.2.4.2 The critical branch shall supply power for task illumination, fixed equipment, select receptacles, and select power circuits serving the following areas and functions related to patient care:

(1) Critical care areas that utilize anesthetizing gases, task illumination, select receptacles, and fixed equipment.

(2) Isolated power systems in special environments.

(3) Task illumination and select receptacles in the following:

(a) Patient care rooms, including infant nurseries, selected acute nursing areas, psychiatric bed areas (omit receptacles), and ward treatment rooms.

(b) Medication preparation areas.

(c) Pharmacy dispensing areas.

(d) Nurses' stations (unless adequately lighted by corridor luminaries).

(4) Additional specialized patient care task illumination and receptacles, where needed.

(5) Nurse call systems.

(6) Blood, bone, and tissue banks.

(7) Telephone equipment rooms and closets.

(8) Task illumination, select receptacles, and select power circuits for the following areas:

(a) General care beds with at least one duplex receptacles per patient bedroom, and task illumination as required by the governing body of the health care facility.

(b) Angiographic labs.

(c) Cardiac catheterization labs.

(d) Coronary care units.

(e) Hemodialysis rooms or areas,

(f) Emergency room treatment areas (select).

(g) Human physiology labs.

(h) Intensive care units.

(i) Postoperative recovery rooms (select).

(9) Additional task illumination, receptacles, and select power circuits needed for effective facility operation, including single-phase fractional horsepower motors, which are permitted to be connected to the critical branch.


Based on observation, the facility had incorrect circuit connected to the essential electrical system.


The surveyor observed, while accompanied by the Director of Engineering, Engineering Supervisor, Quality Control Technician, and Administration Assistant, during the hours of the inspection from 2:00 PM to 6:00 PM on 9/24/2019 and 8:30 am to 1:00 PM on 9/25/2019 that some of the critical panels had circuits that are meant for equipment panel. Re-visit all the critical panels and ensure that they had the only the required circuits on it.

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Regarding L B J H O S P I T A L

(A) There was a missing receptacle powered from life safety branch and a missing battery powered operated light units at the automatic transfer switch location.

(B) The electrical directory was not updated in accordance to the new or modified receptacles.

(C) Emergency panels were not distinctively marked so that they are readily identifiable as a component of the essential electrical system."

(D) The labels provided for the electrical panels and the essential transfer switches were not readily identifiable to identify life safety, critical and equipment branch. This is not in accordance with NFPA 70.

(E) Please verify that there is a bonding wire provided between the normal and essential branch-circuits panel boards. Please reference NFPA 70, 2002: 517-14. - Panel board bonding requires the equipment grounding terminal buses of the normal and essential branch-circuits panel boards serving the same individual patient vicinity be bonded together with an insulated continuous copper conductor not smaller than # 10 AWG.

(F) On the first floor, the main fire alarm control panel and the booster panel shown to be powered from the equipment branch. Please verify and correct it back to the life safety branch. Once the correction is done please provide correct panel and circuit number on the face of the FACP.

(G) At the central plant generator room and the MDF room there were two the electrical panel labels shown to be labeled as normal power however the panel directory shown fire alarm booster panel, auto door, battery charger which shall be powered from the life safety branch. Please very either correct the labeling or correct them to the correct branch.

(H) On the 1st floor and the third floor, the main fire alarm booster panel shown to be powered from the critical branch. Please verify and correct it back to the life safety branch.

(I) Since there were numerous fire alarm booster panel and fire alarm related component were not powered from the life safety branch. Please verify all the fire alarm component will be corrected to the life safety branch.

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Regarding B E N T A U B H O S P I T A L

Based on observation, the facility failed to provide adequate risk assessment for all the operating rooms.

The surveyor observed, while accompanied by the Director of Engineering, Engineering Supervisor, Quality Control Technician, and Administration Assistant, during the hours of the inspection from 2:00 PM to 6:00 PM on 9/24/2019 and 8:30 am to 1:00 PM on 9/25/2019 that risk assessments were not performed by the governing body to determine if the Operating rooms were wet or dry locations. If determined to be wet, they must be protected by line isolation monitors or GFCIs.

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Regarding B E N T A U B H O S P I T A L

Based on observation, the facility failed to provide adequate maintenance and testing of Essential Electrical System.

The inspector observed, while accompanied by the Director of Engineering, Engineering Supervisor, Quality Control Technician, and Administration Assistant, during the hours of the inspection from 2:00 PM to 6:00 PM on 9/24/2019 and 8:30 am to 1:00 PM on 9/25/2019 that:

1. Additional testing was not being performed correctly in terms of referencing each receptacle to the different tests performed on the particular receptacle in the patient care area at intervals defined by documented performance data on all the patient care receptacles. The testing record shall be such that each area and receptacles tested must be identified.

2. No records of where, type of repairs performed, and date of electrical maintenance and required tests performed in all the patient care areas.

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Regarding B E N T A U B H O S P I T A L

Based on observation, the facility failed to provide adequate maintenance and testing of Essential Electrical System.

The surveyor observed, while accompanied by the Director of Engineering, Engineering Supervisor, Quality Control Technician, and Administration Assistant, during the hours of the inspection from 2:00 PM to 6:00 PM on 9/24/2019 and 8:30 am to 1:00 PM on 9/25/2019 that:

1. The main and feeder circuit breakers were not being inspected annually and there was no program for periodically exercising the components.

2. There were no records of maintenance and testing maintained.

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Regarding B E N T A U B H O S P I T A L

Based on observation, the facility failed to provide adequate medical gas equipment testing.

The surveyor observed, while accompanied by the Director of Engineering, Engineering Supervisor, Quality Control Technician, and Administration Assistant, during the hours of the inspection from 2:00 PM to 6:00 PM on 9/24/2019 and 8:30 am to 1:00 PM on 9/25/2019 that the facility had no scheduled maintenance program for medical gas equipment.