HospitalInspections.org

Fire Drill Records

The inspector observed, while accompanied by the Maintenance, during the hours of the inspection from 10:30AM to 1PM on 03/17/2016 that there were the following issues:

A) The facility failed to provide a history of records for Fire Drills.

Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. -NFPA 101, 2000: 19.7.1.2

Fire Alarm System: Cross Ref FACP & Panel/Breaker, Connect to Monitoring

The inspector observed, while accompanied by the Maintenance, during the hours of the inspection from 10:30AM to 1PM on 03/17/2016 that there were the following issues:

A) Based on observation the facility failed to provide an acceptable cross referencing of the fire alarm control panel and the panel and breaker supplying power.

" 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.

Fire Sprinkler System Complete

The inspector observed, while accompanied by the Maintenance, during the hours of the inspection from 10:30AM to 1PM on 03/17/2016 that there were the following issues:

A) The facility failed to provide a history of records for sprinkler system inspection.

Sprinklers shall be inspected from the floor level annually. - NFPA 25, 2002: 5.2.1.1

Type 1 EES & Gen Anesthesia/Life Support, Generator Maintenance re 110, Gen Set Light & Receptacle (Hospital and ASC),

The inspector observed, while accompanied by the Maintenance, during the hours of the inspection from 10:30AM to 1PM on 03/17/2016 that there were the following issues:

A) There was no light with battery backup and receptacle at generator set location.
B) During testing of the generator startup, the generator annunciator panel status indicator LED did not change to reflect the status of the generator operation.

"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, Health Care Facilities Code. U.S.A.: NFPA; 2002: 4.4.2.2.2.2.(5).

HVAC Filter Changes

The inspector observed, while accompanied by the Maintenance, during the hours of the inspection from 10:30AM to 1PM on 03/17/2016 that there were the following issues:

A) The facility failed to provide a history of records for HVAC filter changes. The last documented HVAC filter logs was for the year 2012.
Filtration requirements. All central air handling systems serving patient care areas, including nursing unit corridors, shall be equipped with filters having efficiencies equal to, or greater than, those specified in Table 4 of §133.169(d) of this title. Filter efficiencies shall be average efficiencies tested in accordance with American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE), Inc., Standard 52.2, 1999 edition, Method of Testing General Ventilation Air-Cleaning Devices for Removal Efficiency by Particle Size. All joints between filter segments, and between filter segments and the enclosing ductwork, shall have gaskets and seals to provide a positive seal against air leakage. Air handlers serving more than one room shall be considered as central air handlers. - Hospital Licensing Rules: Title 25, TAC, Ch. 133, HLR. DSHS; 2010: 133.162(d)(3)(D)(ii)

Receptacle Testing in Patient Care Areas

The inspector observed, while accompanied by the Maintenance, during the hours of the inspection from 10:30AM to 1PM on 03/17/2016 that there were the following issues:

A) The facility was not conducting receptacle testing at all. The facility failed to provide a history of records for receptacle testing per NFPA 99: 3-3.3.3. in patient care areas.

"Receptacle Testing in Patient Care Areas per 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)."

"Testing Intervals. (a) The facility shall establish policies and protocols for the type of test and intervals of testing for each appliance. (b) All appliances used in patient care areas shall be tested in accordance with 7-5.1.3 or 7-5.2.2.1 before being put into service for the first time and after repair or modification. Patient-care-related electrical appliances shall be retested at intervals determined by their normal location or area of normal use, but not exceeding the intervals listed below: General care areas - 12 months; critical care areas - 6 months; wet locations - 6 months. " - NFPA 99, 1999, 7-6.2.1.2

Fuel and Water Preferred Customer Status

The inspector observed, while accompanied by the Maintenance, during the hours of the inspection from 10:30AM to 1PM on 03/17/2016 that there were the following issues:

A) The facility failed to provide letters from vendors for emergency fuel and water.

Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) electricity, (b) water, (c) ventilation, (d) fire protection systems, (e) fuel sources, (f) medical gas and vacuum systems (if applicable), and (g) communication systems. -NFPA 99, 1999: 11-5.3.2

NFPA 70, Panel Directories

The inspector observed, while accompanied by the Maintenance, during the hours of the inspection from 10:30AM to 1PM on 03/17/2016 that there were the following issues:

A) Panel " A " circuit directory contained info that was either outdated or misleading and thus not meaningful for staff to be able to readily identify the appropriate circuit breaker when the need arises. Spare breakers are to be labeled with a "SPARE" designation, even though there may be nothing connected to the circuit breaker.
B) Panel " E1 " circuit directory had outdated info and needs to be updated.
C) There was an electrical panel in the Electrical Room that had no cover thus leaving the conductors exposed. According to Maintenance personnel, this panel served the HVAC system. Without a cover in place, accidental direct contact could result in serious injury.

Circuit Directories: Room numbers and areas were not identified on the circuit directory of the panels. All circuits and circuit modifications shall be legibly identified as to purpose of use on the circuit directory located on the face or inside of the panel door in the case of a panel board, and at each switch on a switchboard. - NEC 1999, 384-13.

110.22 Identification of Disconnecting Means. Each disconnecting means shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved. - NEC 2005, 110.22

Physical environment. A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each hospital. The physical premises of the hospital and those areas of the hospital's physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and Subchapters H and I of this chapter. - HLR, 2007, §133.162 (d)(1)(A)

Fire Drill Records

The inspector observed, while accompanied by the Maintenance, during the hours of the inspection from 10:30AM to 1PM on 03/17/2016 that there were the following issues:

A) The facility failed to provide a history of records for Fire Drills.

Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. -NFPA 101, 2000: 19.7.1.2

Fire Alarm System: Cross Ref FACP & Panel/Breaker, Connect to Monitoring

The inspector observed, while accompanied by the Maintenance, during the hours of the inspection from 10:30AM to 1PM on 03/17/2016 that there were the following issues:

A) Based on observation the facility failed to provide an acceptable cross referencing of the fire alarm control panel and the panel and breaker supplying power.

" 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.

Fire Sprinkler System Complete

The inspector observed, while accompanied by the Maintenance, during the hours of the inspection from 10:30AM to 1PM on 03/17/2016 that there were the following issues:

A) The facility failed to provide a history of records for sprinkler system inspection.

Sprinklers shall be inspected from the floor level annually. - NFPA 25, 2002: 5.2.1.1

Type 1 EES & Gen Anesthesia/Life Support, Generator Maintenance re 110, Gen Set Light & Receptacle (Hospital and ASC),

The inspector observed, while accompanied by the Maintenance, during the hours of the inspection from 10:30AM to 1PM on 03/17/2016 that there were the following issues:

A) There was no light with battery backup and receptacle at generator set location.
B) During testing of the generator startup, the generator annunciator panel status indicator LED did not change to reflect the status of the generator operation.

"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, Health Care Facilities Code. U.S.A.: NFPA; 2002: 4.4.2.2.2.2.(5).

HVAC Filter Changes

The inspector observed, while accompanied by the Maintenance, during the hours of the inspection from 10:30AM to 1PM on 03/17/2016 that there were the following issues:

A) The facility failed to provide a history of records for HVAC filter changes. The last documented HVAC filter logs was for the year 2012.
Filtration requirements. All central air handling systems serving patient care areas, including nursing unit corridors, shall be equipped with filters having efficiencies equal to, or greater than, those specified in Table 4 of §133.169(d) of this title. Filter efficiencies shall be average efficiencies tested in accordance with American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE), Inc., Standard 52.2, 1999 edition, Method of Testing General Ventilation Air-Cleaning Devices for Removal Efficiency by Particle Size. All joints between filter segments, and between filter segments and the enclosing ductwork, shall have gaskets and seals to provide a positive seal against air leakage. Air handlers serving more than one room shall be considered as central air handlers. - Hospital Licensing Rules: Title 25, TAC, Ch. 133, HLR. DSHS; 2010: 133.162(d)(3)(D)(ii)

Receptacle Testing in Patient Care Areas

The inspector observed, while accompanied by the Maintenance, during the hours of the inspection from 10:30AM to 1PM on 03/17/2016 that there were the following issues:

A) The facility was not conducting receptacle testing at all. The facility failed to provide a history of records for receptacle testing per NFPA 99: 3-3.3.3. in patient care areas.

"Receptacle Testing in Patient Care Areas per 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)."

"Testing Intervals. (a) The facility shall establish policies and protocols for the type of test and intervals of testing for each appliance. (b) All appliances used in patient care areas shall be tested in accordance with 7-5.1.3 or 7-5.2.2.1 before being put into service for the first time and after repair or modification. Patient-care-related electrical appliances shall be retested at intervals determined by their normal location or area of normal use, but not exceeding the intervals listed below: General care areas - 12 months; critical care areas - 6 months; wet locations - 6 months. " - NFPA 99, 1999, 7-6.2.1.2

Fuel and Water Preferred Customer Status

The inspector observed, while accompanied by the Maintenance, during the hours of the inspection from 10:30AM to 1PM on 03/17/2016 that there were the following issues:

A) The facility failed to provide letters from vendors for emergency fuel and water.

Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) electricity, (b) water, (c) ventilation, (d) fire protection systems, (e) fuel sources, (f) medical gas and vacuum systems (if applicable), and (g) communication systems. -NFPA 99, 1999: 11-5.3.2

NFPA 70, Panel Directories

The inspector observed, while accompanied by the Maintenance, during the hours of the inspection from 10:30AM to 1PM on 03/17/2016 that there were the following issues:

A) Panel " A " circuit directory contained info that was either outdated or misleading and thus not meaningful for staff to be able to readily identify the appropriate circuit breaker when the need arises. Spare breakers are to be labeled with a "SPARE" designation, even though there may be nothing connected to the circuit breaker.
B) Panel " E1 " circuit directory had outdated info and needs to be updated.
C) There was an electrical panel in the Electrical Room that had no cover thus leaving the conductors exposed. According to Maintenance personnel, this panel served the HVAC system. Without a cover in place, accidental direct contact could result in serious injury.

Circuit Directories: Room numbers and areas were not identified on the circuit directory of the panels. All circuits and circuit modifications shall be legibly identified as to purpose of use on the circuit directory located on the face or inside of the panel door in the case of a panel board, and at each switch on a switchboard. - NEC 1999, 384-13.

110.22 Identification of Disconnecting Means. Each disconnecting means shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved. - NEC 2005, 110.22

Physical environment. A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each hospital. The physical premises of the hospital and those areas of the hospital's physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and Subchapters H and I of this chapter. - HLR, 2007, §133.162 (d)(1)(A)