HospitalInspections.org

At Methodist Hospital (Main Campus), the inspector observed while accompanied by the Director of Plant Operations during inspection conducted on 07-18-2016 and 07-19-2016 that the facility failed to assure the integrity of the corridor. Stairwell door on North tower (stairwell 13) did not latch properly.

At Metropolitan Methodist Hospital (Main Tower), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. Location: 3rd Floor: The fire rated double doors leading into the elevator lobby were automatic doors. One door failed to auto close.

At Methodist Hospital (Main Campus), the inspector observed while accompanied by the Manager of Operations during inspection conducted on 07-18-2016 and 07-19-2016 that Level 9 (Central Tower) the 1 hour fire-rated smoke barrier wall construction at the north end of the NORTH ELEVATOR LOBBY was non-compliant. This condition was observed at both sides of the 1 hour fire-rated smoke barrier wall above the cross-corridor doors which closed off the NORTH ELEVATOR LOBBY.


At Methodist Hospital (Main Campus), the inspector observed while accompanied by the Manager of Operations during inspection conducted on 07-18-2016 and 07-19-2016 that Level 9 (Central Tower) the 1 hour fire-rated smoke barrier wall construction at the south end of the SOUTH ELEVATOR LOBBY was non-compliant. A greenish/gray material was used for fire-stopping 2 electrical conduit penetrations thru the north side of the 1 hour fire-rated smoke barrier wall above the cross-corridor doors which closed off the SOUTH ELEVATOR LOBBY. The material does not appear to be an acceptable U.L. approved product.
Additionally, on the south side of the 1 hour fire-rated smoke barrier wall there were multiple non-compliant penetrations where drywall mud was used in lieu of U.L. approved fire-rated sealant. There was also a non-compliant




At Methodist Specialty & Transplant Hospital, based on observation and interview, the facility failed to ensure all smoke barriers were sealed to prevent the passage of smoke, as required by NFPA 101, 2003.

Observations on 07/19/16 from 9:00am to 4:00pm, revealed holes and unsealed pipe penetrations above the ceiling at several locations at corridor walls and cross-corridor door walls at various locations on Levels 1 through 6 including the Mezzanine at required locations.

In an interview during the afternoon of 07/19/16, the Facility Management Director stated that stated that all holes and unsealed penetrations would be properly filled to prevent the passage of smoke and that he had recorded each location where holes were observed. The inspector reviewed and accepted the list prepared by the Facility Management Director.




At Northeast Methodist Hospital, the inspector observed, while accompanied by The COO, Director of Facility Management, ,The Director of the Pharmacy, and Two Facility Management Assistants during the hours of the inspection from 10:00 AM TO 3:50 PM on 07/19/2016 that there were the following issues:

A.) There was one penetration at the walls above the smoke barrier cross corridor doors was not fire caulked.
B.) There was one set of egress cross corridor doors at critical care overflow area located at the smoke compartment was not fully closed upon activation of the fire alarm system.
C.) The vision panels were not provided at the cross corridor doors located on the smoke compartment. According to NFPA 101, 1985 edition chapter 12-3.7.7 - Vision panels of approved transparent wired glass not exceeding 1296 sq in. in approved metal frames shall be provided in each door in a smoke barrier.

At Metropolitan Methodist Hospital (Main Tower), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. Location: 7th Floor: The smoke barrier double doors located near room # 708 failed to close complete when released from the magnetic hold-open.

' ' Doors in smoke barriers shall be self-closing or automatic-closing. ' ' - NFPA 101, 2003: 18.3.7.9.






At Metropolitan Methodist Hospital (Main Tower), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. Location: 4th Floor: The fire rated double doors located near room # 425 have a broken latching mechanism at the top of one of the doors.

" Doors protecting openings into exit corridors shall be provided with positive latching hardware. " - NFPA 101: 2000: 18-3.6.3., NFPA 101: 2003: 18.3.6.3.5.




At Metropolitan Methodist Hospital (Main Tower), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. Location: 3rd Floor: The fire rated double doors leading into the elevator lobby were automatic doors. One door failed to auto close.

' ' Doors in smoke barriers shall be self-closing or automatic-closing. ' ' - NFPA 101, 2003: 18.3.7.9.




At Metropolitan Methodist Hospital (Women Pavilion), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. Location: 3rd Floor: The smoke barrier double doors located near room # 8 failed to close complete when released from the magnetic hold-open.

' ' Doors in smoke barriers shall be self-closing or automatic-closing. ' ' - NFPA 101, 2003: 18.3.7.9.




At Metropolitan Methodist Hospital (Women Pavilion), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. Location: 2nd Floor: The smoke barrier double doors located near the NICU failed to close complete when released from the magnetic hold-open.

' ' Doors in smoke barriers shall be self-closing or automatic-closing. ' ' - NFPA 101, 2003: 18.3.7.9.




At Metropolitan Methodist Hospital (Women Pavilion), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. Location: 2nd Floor: The smoke barrier double doors located near the LDR6 failed to close complete when released from the magnetic hold-open.

' ' Doors in smoke barriers shall be self-closing or automatic-closing. ' ' - NFPA 101, 2003: 18.3.7.9.



At Metropolitan Methodist Hospital (Women Pavilion), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. Location: 1st Floor: The smoke barrier double doors located near the LDR14 failed to close complete when released from the magnetic hold-open.

' ' Doors in smoke barriers shall be self-closing or automatic-closing. ' ' - NFPA 101, 2003: 18.3.7.9.

At Metropolitan Methodist Hospital (Main Tower), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. Location: 7th Floor: The fire rated double doors leading into the elevator lobby failed to have an astragal.

' ' Rabbets, bevels, or astragals shall be required at the meeting edges, and stops shall be required at the head and sides of door frames in smoke barriers. Positive latching hardware shall not be required. Center mullion shall be prohibited. ' ' - NFPA 101, 2003: 18.3.7.10

At Methodist Specialty & Transplant Hospital, based on observation and interview, the facility failed to ensure that there were no unsealed penetrations at all rated walls, which does not meet the requirements of:

NFPA 101, 2003: 8.3.5.1 ..... 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.

Observations on 07/19/16 from 9:00am to 4:00pm, revealed there were unsealed holes and penetrations above the ceiling in the fire rated walls at various locations on Levels 1 through 6 including the Mezzanine at required locations such as the walls of Soiled Linen Rooms and Janitor's Closets.

In an interview during the afternoon of 07/19/16, the Facility Management Director stated that the holes and penetrations would be properly sealed to achieve the required fire rating and that he had recorded each location where holes were observed. The inspector reviewed and accepted the list prepared by the Facility Management Director.

Hazardous areas separated from other parts of the building by fire barriers have at least one hour fire resistance rating or such areas are enclosed with smoke partitions and doors and the area is provided with an automatic sprinkler system. High hazard areas are provided with both fire barriers and sprinkler systems. 8.4, 38.3.2, 39.3.2






At Northeast Methodist Hospital, the inspector observed, while accompanied by The COO, Director of Facility Management, ,The Director of the Pharmacy, and Two Facility Management Assistants during the hours of the inspection from 10:00 AM TO 3:50 PM on 07/19/2016 that there were the following issues:

A.) The door closer was not provided at the two hours fire rated door between the Chiller room and the Electrical room.
B.) The UL fire rated door label was not visible at the two hours fire rated door between the Chiller room and the Electrical room. Please verify and provided UL listed fire rated label.

At Methodist Texsan Hospital, the inspector observed, while accompanied by The CEO, CFO, Operation Administrator, Vice President of Nursing, Director of Nursing and Risk Management, Chief Nursing Officer, and The Director of the Plant Maintenance, during the hours of the inspection from 9:00 AM TO 12:30 PM on 07/20/2016 that there were the following issues. They were the following issues.
A.) Two exit signage were not provided; one at the egress corridor located near the NW nurse station and one at the SE nurse station on the second floor.
B.) One exit signage was not provided at the egress corridor at the loading dock corridor on the first floor near Cath Lab suite.
C.) Two exit signage were not provided; one at the rack room and on at the decontamination room on the First floor within the surgical suite.
D.) The radiology department on the second floor leading to the egress corridor was locked with a thumb turn device. Revise hardware so door is never locked from inside of suite so there is a free egress out to an exit.
"NFPA 101 Chapter Access to exits shall be marked by approved, readily visible sign in all cases where the exit or way to reach the exit is not readily apparent to the occupant.

At Methodist Hospital (Main Campus), the inspector observed while accompanied by the Director of Plant Operations during inspection conducted on 07-18-2016 and 07-19-2016 that an exit sign was required by children ' s emergency department on Children ' s tower by room #6.




At Methodist Specialty & Transplant Hospital, based on observation and interview, the facility failed to ensure that all required exit signs were installed to assure safe egress, which does not meet the requirements of:

NFPA 101, 2003: 7.10.1.5.1 ..... Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants.

Observations on 07/19/16 from 9:00am to 4:00pm, revealed there were occupied spaces that did not have exit signs to indicate location of safe passage at various locations on Levels 1 through 6 including the Mezzanine such as the large mechanical rooms, adjoining rooms, waiting rooms, etc.

In an interview during the afternoon of 07/19/16, the Facility Management Director stated that the all required exit signs would be properly installed and that he had recorded each location where holes were observed. The inspector reviewed and accepted the list prepared by the Facility Management Director.

At Metropolitan Methodist Hospital (Women Pavilion), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. First floor electrical room: Life Safety Panel: The breaker for the fire alarm system failed to be marked per the following requirements.

" A dedicated electrical circuit to the life safety branch of the EES shall be provided. The circuit shall be identified with a red marking and identified as "FIRE ALARM CIRCUIT CONTROL". - NFPA 72, 1999: 1-5.2.5.2.

At Methodist Hospital (Main Campus), the inspector observed while accompanied by the Director of Plant Operations during inspection conducted on 07-18-2016 and 07-19-2016 that sprinkler head was missing from cooler/freezer #1 located on kitchen area sl1 central tower.



At Metropolitan Methodist Hospital (Main Tower), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there was the following issue. In the Fire Pump Room there is a spare sprinkler head box. The required sprinkler head wrench was missing.

A special sprinkler wrench shall also be provided and kept in the cabinet to be used in the removal and installation of sprinklers. - NFPA 13, 1999, 3-2.9.2

At Methodist Texsan Hospital, the inspector observed, while accompanied by The CEO, CFO, Operation Administrator, Vice President of Nursing, Director of Nursing and Risk Management, Chief Nursing Officer, and The Director of the Plant Maintenance, during the hours of the inspection from 9:00 AM TO 12:30 PM on 07/20/2016 that there were the following issues. They were the following issues.
A.) It was unclear that the receptacle was powered from life safety branch at the generator set location.
B.) The circuit breaker for the fire alarm is not marked red.
" 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 "

" 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.



At Metropolitan Methodist Hospital (Main Tower), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there was the following issue. The required receptacle testing was being conducted on a random basis on an unspecified percentage of total patient care area receptacles. Please verify that at least 10% of the receptacles are being tested during each testing interval, and at least 10% in each patient care type, including patient room headboards.

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 in patient care areas. Since this data is not typically available and practical to use, testing once per year in all patient care areas is acceptable.






At Metropolitan Methodist Hospital (Main Tower), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. The facility failed to provide task illumination with battery backup for the two outdoor emergency electrical generators.

' ' Generator Set Location: Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location and essential electrical system transfer switch locations. ' ' - NFPA 99, 2002: 4.4.2.2.2.2.(5).




At Northeast Methodist Hospital, the inspector observed, while accompanied by The COO, Director of Facility Management, ,The Director of the Pharmacy, and Two Facility Management Assistants during the hours of the inspection from 10:00 AM TO 3:50 PM on 07/19/2016 that there were the following issues. They were the following issues:

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

" 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.

At Methodist Hospital (Main Campus), the inspector observed while accompanied by the Director of Plant Operations during inspection conducted on 07-18-2016 and 07-19-2016 that walls at Infusion room were not labeled 1hr walls. Verify walls shall be stenciled.



At Methodist Specialty & Transplant Hospital, based on observation and interview, the facility failed to ensure that all nurse call systems were fully functional, which does not meet the requirements of:

HLR 2007: §133.162(d)(5)(L)(ii) .....A nurses emergency calling system shall be installed in all toilets used by patients to summon nursing staff in an emergency. Activation of the system shall sound a repeating (every 5 seconds or less) a distinct audible signal at the nurse station, indicate type and location of call on the system monitor, and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. The visible and audible signals shall be cancelable only at the patient calling station. Calls shall activate visible signals in accordance with Table 7 of §133.169(g) of this title. When conveniently located and accessible from both the bathing and toilet fixtures, one emergency call station may serve one bathroom. A nurse ' s emergency call system shall be accessible to a collapsed patient lying on the floor. Inclusion of a pull cord extending to within six inches of the floor will satisfy this requirement.

HLR 2007: §133.162(d)(5)(L)(iii) ..... Activation of the system will sound a distinct audible signal at the nursing unit's nurses station or at a staffed control station of a suite, department or unit, indicate type and location of call on the system monitor and activate a distinct visible signal in the corridor at the patient suites door.

Observations on 07/19/16 from 9:00am to 4:00pm, revealed there were nurse call monitors in unoccupied patient rooms without audio communications from the Nurse Station at two locations on Levels 1 and 2.

In an interview during the afternoon of 07/19/16, the Facility Management Director stated that the nurse call system at these two locations would be repaired and that he had recorded each location. The inspector reviewed and accepted the list prepared by the Facility Management Director.






At Methodist Specialty & Transplant Hospital, based on observation and interview, the facility failed to ensure that all exhaust fans were functional, which does not meet the requirements of:

HLR, 2007: §133.163 (t)(3)(C) ... ... The isolation room exhaust shall be a dedicated system which exhausts all air continuously to the exterior in accordance with Table 3 of §133.169(c) of this title. Multiple isolation rooms may be interconnected to the same exhaust system.

NFPA 99; 2002: 4.4.2.2.3.4 ... ... The following equipment shall be permitted to be arranged for delayed-automatic connection to the alternate power source: (6) Supply, return, and exhaust ventilating systems for air-borne infectious/isolation rooms, protective environment rooms .... Where delayed automatic connection is not appropriate, such ventilation systems shall be permitted to be placed on the critical branch.

Observations on 07/19/16 from 9:00am to 4:00pm, revealed there were exhaust fans in restrooms and soiled utility rooms that appeared to not provide negative air movement on Levels 1, Mezzanine, 3 and 4.

In an interview during the afternoon of 07/19/16, the Facility Management Director stated that all exhaust fans will be adjusted or replaced to be fully operational and that he had recorded each location. The inspector reviewed and accepted the list prepared by the Facility Management Director.






At Methodist Specialty & Transplant Hospital, based on observation and interview, the facility failed to ensure that all visual notification signal devices (strobes) connected to the fire alarm system were installed at required locations, such as restrooms, hallways, general use areas, etc., which does not meet the requirements of:

NFPA 72; 2002: 7.5 and ADA rules and regulation 4.28.1 and 4.28.3 stipulate a visual appliance shall be provided on buildings and facilities in each of the following areas: Restroom and any other general usage areas (e.g. meeting rooms), hallways, lobbies, and any other areas for common use.
TAS 4.28.3 .....Visual alarm signals shall have the following minimum photometric and location features: (3) The maximum pulse duration shall be two-tenths of one second (0.2 sec) with a maximum duty cycle of 40 percent. The pulse duration is defined as the time interval between initial and final points of 10 percent of maximum signal (4) The intensity shall be a minimum of 75 candela and (5) The flash rate shall be a minimum of 1 Hz and a maximum of 3 Hz.

Observations on 07/19/16 from 2:30pm to 3:10pm, revealed there were missing visual notification signal devices (strobes) connected to the fire alarm system at the Mezzanine in the areas where offices were constructed.

In an interview during the afternoon of 07/19/16, the Facility Management Director stated that all the facility employed fire alarm company will be requested to evaluate the area and required strobes will be add.





At Methodist Specialty & Transplant Hospital, based on observation and interview, the facility failed to ensure that all fire sprinklers were installed at required locations, such as under fixed obstructions over 4 feet wide, which does not meet the requirements of:

NFPA 13, 2002: 8.5.5.3.1 ..... Sprinklers shall be installed under fixed obstructions over 4 feet wide such as ducts, decks, open grate flooring, cutting tables and overhead doors.

Observations on 07/19/16 from 2:30pm to 3:10pm, revealed there were missing fire sprinklers were installed below fixed obstructions over four feet wide in the Mezzanine at raised equipment and ducts.

In an interview during the afternoon of 07/19/16, the Facility Management Director stated that all the facility employed fire sprinkler company will be requested to evaluate the area and required sprinklers will be add.



At Metropolitan Methodist Hospital, the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there was the following issue. The required receptacle testing was being conducted on a random basis on an unspecified percentage of total patient care area receptacles. Please verify that at least 10% of the receptacles are being tested during each testing interval, and at least 10% in each patient care type, including patient room headboards.

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 in patient care areas. Since this data is not typically available and practical to use, testing once per year in all patient care areas is acceptable.




At Metropolitan Methodist Hospital (Main Tower), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there was the following issue. In the boiler room there is an electrical panel box located near the boiler that was missing a panel door latching mechanism. This panel door was open.

Electrical installations. All new electrical material and equipment, including conductors, controls, and signaling devices, shall be installed in compliance with applicable sections of the National Fire Protection Association 70, National Electrical Code, 1999 edition (NFPA 70), and NFPA 99 and as necessary to provide a complete electrical system. Electrical systems and components shall be listed by nationally recognized listing agencies as complying with available standards and shall be installed in accordance with the listings and manufacturers' instructions.




At Metropolitan Methodist Hospital (ACC Building), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. Location: 2nd Floor: Two electrical rooms were being used for storage of electrical supplies. This fails to meet code regulations per the following requirements.

' ' Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded. ' ' - NFPA 70, 2002, 110.26(B)

' ' Dedicated Equipment Space: All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage. ' ' - NFPA 70, 2002, 110.26(F)

At Metropolitan Methodist Hospital (ACC Building), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. Location: 2nd and 3rd Floor Cath Labs and SICU areas: The critical care (red) receptacles were not labeled per the following requirements.

In critical care areas, emergency system receptacles must be labeled to indicate the panel board and circuit number supplying them in accordance with NFPA 70, 1999: 517-19(a). The identification label shall be permanent either by engraving the cover plates or permanent adhesive engraved laminated labels.

At Methodist Hospital (Main Campus), the inspector observed while accompanied by the Director of Plant Operations during inspection conducted on 07-18-2016 and 07-19-2016 that the facility failed to assure the integrity of the corridor. Stairwell door on North tower (stairwell 13) did not latch properly.

At Metropolitan Methodist Hospital (Main Tower), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. Location: 3rd Floor: The fire rated double doors leading into the elevator lobby were automatic doors. One door failed to auto close.

At Methodist Hospital (Main Campus), the inspector observed while accompanied by the Manager of Operations during inspection conducted on 07-18-2016 and 07-19-2016 that Level 9 (Central Tower) the 1 hour fire-rated smoke barrier wall construction at the north end of the NORTH ELEVATOR LOBBY was non-compliant. This condition was observed at both sides of the 1 hour fire-rated smoke barrier wall above the cross-corridor doors which closed off the NORTH ELEVATOR LOBBY.


At Methodist Hospital (Main Campus), the inspector observed while accompanied by the Manager of Operations during inspection conducted on 07-18-2016 and 07-19-2016 that Level 9 (Central Tower) the 1 hour fire-rated smoke barrier wall construction at the south end of the SOUTH ELEVATOR LOBBY was non-compliant. A greenish/gray material was used for fire-stopping 2 electrical conduit penetrations thru the north side of the 1 hour fire-rated smoke barrier wall above the cross-corridor doors which closed off the SOUTH ELEVATOR LOBBY. The material does not appear to be an acceptable U.L. approved product.
Additionally, on the south side of the 1 hour fire-rated smoke barrier wall there were multiple non-compliant penetrations where drywall mud was used in lieu of U.L. approved fire-rated sealant. There was also a non-compliant




At Methodist Specialty & Transplant Hospital, based on observation and interview, the facility failed to ensure all smoke barriers were sealed to prevent the passage of smoke, as required by NFPA 101, 2003.

Observations on 07/19/16 from 9:00am to 4:00pm, revealed holes and unsealed pipe penetrations above the ceiling at several locations at corridor walls and cross-corridor door walls at various locations on Levels 1 through 6 including the Mezzanine at required locations.

In an interview during the afternoon of 07/19/16, the Facility Management Director stated that stated that all holes and unsealed penetrations would be properly filled to prevent the passage of smoke and that he had recorded each location where holes were observed. The inspector reviewed and accepted the list prepared by the Facility Management Director.




At Northeast Methodist Hospital, the inspector observed, while accompanied by The COO, Director of Facility Management, ,The Director of the Pharmacy, and Two Facility Management Assistants during the hours of the inspection from 10:00 AM TO 3:50 PM on 07/19/2016 that there were the following issues:

A.) There was one penetration at the walls above the smoke barrier cross corridor doors was not fire caulked.
B.) There was one set of egress cross corridor doors at critical care overflow area located at the smoke compartment was not fully closed upon activation of the fire alarm system.
C.) The vision panels were not provided at the cross corridor doors located on the smoke compartment. According to NFPA 101, 1985 edition chapter 12-3.7.7 - Vision panels of approved transparent wired glass not exceeding 1296 sq in. in approved metal frames shall be provided in each door in a smoke barrier.

At Metropolitan Methodist Hospital (Main Tower), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. Location: 7th Floor: The smoke barrier double doors located near room # 708 failed to close complete when released from the magnetic hold-open.

' ' Doors in smoke barriers shall be self-closing or automatic-closing. ' ' - NFPA 101, 2003: 18.3.7.9.






At Metropolitan Methodist Hospital (Main Tower), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. Location: 4th Floor: The fire rated double doors located near room # 425 have a broken latching mechanism at the top of one of the doors.

" Doors protecting openings into exit corridors shall be provided with positive latching hardware. " - NFPA 101: 2000: 18-3.6.3., NFPA 101: 2003: 18.3.6.3.5.




At Metropolitan Methodist Hospital (Main Tower), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. Location: 3rd Floor: The fire rated double doors leading into the elevator lobby were automatic doors. One door failed to auto close.

' ' Doors in smoke barriers shall be self-closing or automatic-closing. ' ' - NFPA 101, 2003: 18.3.7.9.




At Metropolitan Methodist Hospital (Women Pavilion), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. Location: 3rd Floor: The smoke barrier double doors located near room # 8 failed to close complete when released from the magnetic hold-open.

' ' Doors in smoke barriers shall be self-closing or automatic-closing. ' ' - NFPA 101, 2003: 18.3.7.9.




At Metropolitan Methodist Hospital (Women Pavilion), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. Location: 2nd Floor: The smoke barrier double doors located near the NICU failed to close complete when released from the magnetic hold-open.

' ' Doors in smoke barriers shall be self-closing or automatic-closing. ' ' - NFPA 101, 2003: 18.3.7.9.




At Metropolitan Methodist Hospital (Women Pavilion), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. Location: 2nd Floor: The smoke barrier double doors located near the LDR6 failed to close complete when released from the magnetic hold-open.

' ' Doors in smoke barriers shall be self-closing or automatic-closing. ' ' - NFPA 101, 2003: 18.3.7.9.



At Metropolitan Methodist Hospital (Women Pavilion), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. Location: 1st Floor: The smoke barrier double doors located near the LDR14 failed to close complete when released from the magnetic hold-open.

' ' Doors in smoke barriers shall be self-closing or automatic-closing. ' ' - NFPA 101, 2003: 18.3.7.9.

At Metropolitan Methodist Hospital (Main Tower), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. Location: 7th Floor: The fire rated double doors leading into the elevator lobby failed to have an astragal.

' ' Rabbets, bevels, or astragals shall be required at the meeting edges, and stops shall be required at the head and sides of door frames in smoke barriers. Positive latching hardware shall not be required. Center mullion shall be prohibited. ' ' - NFPA 101, 2003: 18.3.7.10

At Methodist Specialty & Transplant Hospital, based on observation and interview, the facility failed to ensure that there were no unsealed penetrations at all rated walls, which does not meet the requirements of:

NFPA 101, 2003: 8.3.5.1 ..... 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.

Observations on 07/19/16 from 9:00am to 4:00pm, revealed there were unsealed holes and penetrations above the ceiling in the fire rated walls at various locations on Levels 1 through 6 including the Mezzanine at required locations such as the walls of Soiled Linen Rooms and Janitor's Closets.

In an interview during the afternoon of 07/19/16, the Facility Management Director stated that the holes and penetrations would be properly sealed to achieve the required fire rating and that he had recorded each location where holes were observed. The inspector reviewed and accepted the list prepared by the Facility Management Director.

Hazardous areas separated from other parts of the building by fire barriers have at least one hour fire resistance rating or such areas are enclosed with smoke partitions and doors and the area is provided with an automatic sprinkler system. High hazard areas are provided with both fire barriers and sprinkler systems. 8.4, 38.3.2, 39.3.2






At Northeast Methodist Hospital, the inspector observed, while accompanied by The COO, Director of Facility Management, ,The Director of the Pharmacy, and Two Facility Management Assistants during the hours of the inspection from 10:00 AM TO 3:50 PM on 07/19/2016 that there were the following issues:

A.) The door closer was not provided at the two hours fire rated door between the Chiller room and the Electrical room.
B.) The UL fire rated door label was not visible at the two hours fire rated door between the Chiller room and the Electrical room. Please verify and provided UL listed fire rated label.

At Methodist Texsan Hospital, the inspector observed, while accompanied by The CEO, CFO, Operation Administrator, Vice President of Nursing, Director of Nursing and Risk Management, Chief Nursing Officer, and The Director of the Plant Maintenance, during the hours of the inspection from 9:00 AM TO 12:30 PM on 07/20/2016 that there were the following issues. They were the following issues.
A.) Two exit signage were not provided; one at the egress corridor located near the NW nurse station and one at the SE nurse station on the second floor.
B.) One exit signage was not provided at the egress corridor at the loading dock corridor on the first floor near Cath Lab suite.
C.) Two exit signage were not provided; one at the rack room and on at the decontamination room on the First floor within the surgical suite.
D.) The radiology department on the second floor leading to the egress corridor was locked with a thumb turn device. Revise hardware so door is never locked from inside of suite so there is a free egress out to an exit.
"NFPA 101 Chapter Access to exits shall be marked by approved, readily visible sign in all cases where the exit or way to reach the exit is not readily apparent to the occupant.

At Methodist Hospital (Main Campus), the inspector observed while accompanied by the Director of Plant Operations during inspection conducted on 07-18-2016 and 07-19-2016 that an exit sign was required by children ' s emergency department on Children ' s tower by room #6.




At Methodist Specialty & Transplant Hospital, based on observation and interview, the facility failed to ensure that all required exit signs were installed to assure safe egress, which does not meet the requirements of:

NFPA 101, 2003: 7.10.1.5.1 ..... Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants.

Observations on 07/19/16 from 9:00am to 4:00pm, revealed there were occupied spaces that did not have exit signs to indicate location of safe passage at various locations on Levels 1 through 6 including the Mezzanine such as the large mechanical rooms, adjoining rooms, waiting rooms, etc.

In an interview during the afternoon of 07/19/16, the Facility Management Director stated that the all required exit signs would be properly installed and that he had recorded each location where holes were observed. The inspector reviewed and accepted the list prepared by the Facility Management Director.

At Metropolitan Methodist Hospital (Women Pavilion), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. First floor electrical room: Life Safety Panel: The breaker for the fire alarm system failed to be marked per the following requirements.

" A dedicated electrical circuit to the life safety branch of the EES shall be provided. The circuit shall be identified with a red marking and identified as "FIRE ALARM CIRCUIT CONTROL". - NFPA 72, 1999: 1-5.2.5.2.

At Methodist Hospital (Main Campus), the inspector observed while accompanied by the Director of Plant Operations during inspection conducted on 07-18-2016 and 07-19-2016 that sprinkler head was missing from cooler/freezer #1 located on kitchen area sl1 central tower.



At Metropolitan Methodist Hospital (Main Tower), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there was the following issue. In the Fire Pump Room there is a spare sprinkler head box. The required sprinkler head wrench was missing.

A special sprinkler wrench shall also be provided and kept in the cabinet to be used in the removal and installation of sprinklers. - NFPA 13, 1999, 3-2.9.2

At Methodist Texsan Hospital, the inspector observed, while accompanied by The CEO, CFO, Operation Administrator, Vice President of Nursing, Director of Nursing and Risk Management, Chief Nursing Officer, and The Director of the Plant Maintenance, during the hours of the inspection from 9:00 AM TO 12:30 PM on 07/20/2016 that there were the following issues. They were the following issues.
A.) It was unclear that the receptacle was powered from life safety branch at the generator set location.
B.) The circuit breaker for the fire alarm is not marked red.
" 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 "

" 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.



At Metropolitan Methodist Hospital (Main Tower), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there was the following issue. The required receptacle testing was being conducted on a random basis on an unspecified percentage of total patient care area receptacles. Please verify that at least 10% of the receptacles are being tested during each testing interval, and at least 10% in each patient care type, including patient room headboards.

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 in patient care areas. Since this data is not typically available and practical to use, testing once per year in all patient care areas is acceptable.






At Metropolitan Methodist Hospital (Main Tower), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. The facility failed to provide task illumination with battery backup for the two outdoor emergency electrical generators.

' ' Generator Set Location: Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location and essential electrical system transfer switch locations. ' ' - NFPA 99, 2002: 4.4.2.2.2.2.(5).




At Northeast Methodist Hospital, the inspector observed, while accompanied by The COO, Director of Facility Management, ,The Director of the Pharmacy, and Two Facility Management Assistants during the hours of the inspection from 10:00 AM TO 3:50 PM on 07/19/2016 that there were the following issues. They were the following issues:

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

" 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.

At Methodist Hospital (Main Campus), the inspector observed while accompanied by the Director of Plant Operations during inspection conducted on 07-18-2016 and 07-19-2016 that walls at Infusion room were not labeled 1hr walls. Verify walls shall be stenciled.



At Methodist Specialty & Transplant Hospital, based on observation and interview, the facility failed to ensure that all nurse call systems were fully functional, which does not meet the requirements of:

HLR 2007: §133.162(d)(5)(L)(ii) .....A nurses emergency calling system shall be installed in all toilets used by patients to summon nursing staff in an emergency. Activation of the system shall sound a repeating (every 5 seconds or less) a distinct audible signal at the nurse station, indicate type and location of call on the system monitor, and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. The visible and audible signals shall be cancelable only at the patient calling station. Calls shall activate visible signals in accordance with Table 7 of §133.169(g) of this title. When conveniently located and accessible from both the bathing and toilet fixtures, one emergency call station may serve one bathroom. A nurse ' s emergency call system shall be accessible to a collapsed patient lying on the floor. Inclusion of a pull cord extending to within six inches of the floor will satisfy this requirement.

HLR 2007: §133.162(d)(5)(L)(iii) ..... Activation of the system will sound a distinct audible signal at the nursing unit's nurses station or at a staffed control station of a suite, department or unit, indicate type and location of call on the system monitor and activate a distinct visible signal in the corridor at the patient suites door.

Observations on 07/19/16 from 9:00am to 4:00pm, revealed there were nurse call monitors in unoccupied patient rooms without audio communications from the Nurse Station at two locations on Levels 1 and 2.

In an interview during the afternoon of 07/19/16, the Facility Management Director stated that the nurse call system at these two locations would be repaired and that he had recorded each location. The inspector reviewed and accepted the list prepared by the Facility Management Director.






At Methodist Specialty & Transplant Hospital, based on observation and interview, the facility failed to ensure that all exhaust fans were functional, which does not meet the requirements of:

HLR, 2007: §133.163 (t)(3)(C) ... ... The isolation room exhaust shall be a dedicated system which exhausts all air continuously to the exterior in accordance with Table 3 of §133.169(c) of this title. Multiple isolation rooms may be interconnected to the same exhaust system.

NFPA 99; 2002: 4.4.2.2.3.4 ... ... The following equipment shall be permitted to be arranged for delayed-automatic connection to the alternate power source: (6) Supply, return, and exhaust ventilating systems for air-borne infectious/isolation rooms, protective environment rooms .... Where delayed automatic connection is not appropriate, such ventilation systems shall be permitted to be placed on the critical branch.

Observations on 07/19/16 from 9:00am to 4:00pm, revealed there were exhaust fans in restrooms and soiled utility rooms that appeared to not provide negative air movement on Levels 1, Mezzanine, 3 and 4.

In an interview during the afternoon of 07/19/16, the Facility Management Director stated that all exhaust fans will be adjusted or replaced to be fully operational and that he had recorded each location. The inspector reviewed and accepted the list prepared by the Facility Management Director.






At Methodist Specialty & Transplant Hospital, based on observation and interview, the facility failed to ensure that all visual notification signal devices (strobes) connected to the fire alarm system were installed at required locations, such as restrooms, hallways, general use areas, etc., which does not meet the requirements of:

NFPA 72; 2002: 7.5 and ADA rules and regulation 4.28.1 and 4.28.3 stipulate a visual appliance shall be provided on buildings and facilities in each of the following areas: Restroom and any other general usage areas (e.g. meeting rooms), hallways, lobbies, and any other areas for common use.
TAS 4.28.3 .....Visual alarm signals shall have the following minimum photometric and location features: (3) The maximum pulse duration shall be two-tenths of one second (0.2 sec) with a maximum duty cycle of 40 percent. The pulse duration is defined as the time interval between initial and final points of 10 percent of maximum signal (4) The intensity shall be a minimum of 75 candela and (5) The flash rate shall be a minimum of 1 Hz and a maximum of 3 Hz.

Observations on 07/19/16 from 2:30pm to 3:10pm, revealed there were missing visual notification signal devices (strobes) connected to the fire alarm system at the Mezzanine in the areas where offices were constructed.

In an interview during the afternoon of 07/19/16, the Facility Management Director stated that all the facility employed fire alarm company will be requested to evaluate the area and required strobes will be add.





At Methodist Specialty & Transplant Hospital, based on observation and interview, the facility failed to ensure that all fire sprinklers were installed at required locations, such as under fixed obstructions over 4 feet wide, which does not meet the requirements of:

NFPA 13, 2002: 8.5.5.3.1 ..... Sprinklers shall be installed under fixed obstructions over 4 feet wide such as ducts, decks, open grate flooring, cutting tables and overhead doors.

Observations on 07/19/16 from 2:30pm to 3:10pm, revealed there were missing fire sprinklers were installed below fixed obstructions over four feet wide in the Mezzanine at raised equipment and ducts.

In an interview during the afternoon of 07/19/16, the Facility Management Director stated that all the facility employed fire sprinkler company will be requested to evaluate the area and required sprinklers will be add.



At Metropolitan Methodist Hospital, the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there was the following issue. The required receptacle testing was being conducted on a random basis on an unspecified percentage of total patient care area receptacles. Please verify that at least 10% of the receptacles are being tested during each testing interval, and at least 10% in each patient care type, including patient room headboards.

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 in patient care areas. Since this data is not typically available and practical to use, testing once per year in all patient care areas is acceptable.




At Metropolitan Methodist Hospital (Main Tower), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there was the following issue. In the boiler room there is an electrical panel box located near the boiler that was missing a panel door latching mechanism. This panel door was open.

Electrical installations. All new electrical material and equipment, including conductors, controls, and signaling devices, shall be installed in compliance with applicable sections of the National Fire Protection Association 70, National Electrical Code, 1999 edition (NFPA 70), and NFPA 99 and as necessary to provide a complete electrical system. Electrical systems and components shall be listed by nationally recognized listing agencies as complying with available standards and shall be installed in accordance with the listings and manufacturers' instructions.




At Metropolitan Methodist Hospital (ACC Building), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. Location: 2nd Floor: Two electrical rooms were being used for storage of electrical supplies. This fails to meet code regulations per the following requirements.

' ' Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded. ' ' - NFPA 70, 2002, 110.26(B)

' ' Dedicated Equipment Space: All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage. ' ' - NFPA 70, 2002, 110.26(F)

At Metropolitan Methodist Hospital (ACC Building), the inspector observed, while accompanied by the Director of Facility Engineering during the hours of the inspection from 9:00 am to 3:45 pm on 7/19/2016 that there were the following issues. Location: 2nd and 3rd Floor Cath Labs and SICU areas: The critical care (red) receptacles were not labeled per the following requirements.

In critical care areas, emergency system receptacles must be labeled to indicate the panel board and circuit number supplying them in accordance with NFPA 70, 1999: 517-19(a). The identification label shall be permanent either by engraving the cover plates or permanent adhesive engraved laminated labels.