HospitalInspections.org

K0130 Relative Humidity in Anesthetizing Locations

Findings:
The inspector observed, while accompanied by the Director of Environmental Services, during the hours of the inspection from 2:30 PM to 6:30 PM on 08/02/2016 that there were the following issues:

A) The facility failed to maintain relative humidity, RH, within the minimum and maximum limits. Please note according to ASHRAE and State of Texas Regulations, the upper limit for RH shall be < 60% at all times. Per Hospital Licensing Rules (2007), the minimum limit for RH shall be > 30%.

The Standard:
Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures. - NFPA 99, Health Care Facilities Code. U.S.A.: NFPA; 1999: 5-6.1.1

Hospital Licensing Rules: Title 25, TAC, Ch. 133, HLR. DSHS; 2010: Table 3 of H.L.R. 133.169(c) " Ventilations requirements for hospitals and outpatient facilities "


K0130 Disaster Drills Hospitals

Findings:
The inspector observed, while accompanied by the Director of Environmental Services, during the hours of the inspection from 2:30 PM to 6:30 PM on 08/02/2016 that there were the following issues:

A) Based on observation the facility failed to provide records of documentation of rehearsals for the last three years, in order to ensure that there was no lapse in disaster drills. There was an active shooter drill along with its after action report conducted in 2014; other years were not available for review.

The Standard:
"Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least on semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both. " - NFPA 99, Health Care Facilities Code. U.S.A.: NFPA; 1999, 11-5.3.9.

K0145 Type I EES, EES Panel Labels, Line Isolation Monitors

Findings:
The inspector observed, while accompanied by the Director of Environmental Services, during the hours of the inspection from 2:30 PM to 6:30 PM on 08/02/2016 that there were the following issues:

A) Critical panel " E2 " was missing its circuit directory placard.

The Standard:
All circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel door in the case of a panelboard, and at each switch on a switchboard. - NEC 2002 408.4

K0130 Relative Humidity in Anesthetizing Locations

Findings:
The inspector observed, while accompanied by the Director of Environmental Services, during the hours of the inspection from 2:30 PM to 6:30 PM on 08/02/2016 that there were the following issues:

A) The facility failed to maintain relative humidity, RH, within the minimum and maximum limits. Please note according to ASHRAE and State of Texas Regulations, the upper limit for RH shall be < 60% at all times. Per Hospital Licensing Rules (2007), the minimum limit for RH shall be > 30%.

The Standard:
Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures. - NFPA 99, Health Care Facilities Code. U.S.A.: NFPA; 1999: 5-6.1.1

Hospital Licensing Rules: Title 25, TAC, Ch. 133, HLR. DSHS; 2010: Table 3 of H.L.R. 133.169(c) " Ventilations requirements for hospitals and outpatient facilities "


K0130 Disaster Drills Hospitals

Findings:
The inspector observed, while accompanied by the Director of Environmental Services, during the hours of the inspection from 2:30 PM to 6:30 PM on 08/02/2016 that there were the following issues:

A) Based on observation the facility failed to provide records of documentation of rehearsals for the last three years, in order to ensure that there was no lapse in disaster drills. There was an active shooter drill along with its after action report conducted in 2014; other years were not available for review.

The Standard:
"Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least on semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both. " - NFPA 99, Health Care Facilities Code. U.S.A.: NFPA; 1999, 11-5.3.9.

K0145 Type I EES, EES Panel Labels, Line Isolation Monitors

Findings:
The inspector observed, while accompanied by the Director of Environmental Services, during the hours of the inspection from 2:30 PM to 6:30 PM on 08/02/2016 that there were the following issues:

A) Critical panel " E2 " was missing its circuit directory placard.

The Standard:
All circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel door in the case of a panelboard, and at each switch on a switchboard. - NEC 2002 408.4