HospitalInspections.org

Based on observations during the survey walk of the facility on the morning of 6/14/2017 with the Director of Supply Services, the facility failed to maintain a clear and unobstructed path to the egress exit door. A wheeled cart was parked in front of egress doors at east wing. This rolling piece of furniture was present the entire time of survey (longer than 30 minutes).

Based on observations during the survey walk of the facility on the morning of 6/14/2017 with the Director of Supply Services, nurse call duty station was missing at OB wing's soiled utility. The box was there but the actual station was missing.
HLR, 2007: Figure: 25 TAC §133.169 (g), Table 7 ... ... The nurse regular call system shall annunciate at the following rooms: Nurse Station, Clean Work Room, Soiled Work Room, Medication Room, Charting Room, Clean Linen Storage, Nourishment Room, Equipment Storage.



Based on observations during the survey walk of the facility on the morning of 6/14/2017 with the Director of Supply Services, medical gas outlets were in soiled utility holding room, across from surgical department. Please either plate over them or explain why a hazardous area has med gas outlets.

Based on observations during the survey walk of the facility on the morning of 6/14/2017 with the Director of Supply Services, the facility failed to maintain the exit stairwell from administration area. Storage of maintenance items were located in that stairwell.

NFPA 101, 2012: 7.2.2.5.3 .... Enclosed, usable spaces within exit enclosures shall be prohibited, including under the stairs, unless otherwise permitted by 7.2.2.5.3.2
NFPA 101, 2012: 7.2.2.5.3.2 .... Enclosed, usable space shall be permitted under the stairs, provided that both of the following criteria are met: (1) The space shall be separated from the stair enclosure by the same fire resistance as the exit enclosure. (2) Entrance to the enclosed usable space shall not be from within the stair enclosure.

Based on observations during the survey walk of the facility on the morning of 6/14/2017 with the Director of Supply Services, the facility's fire sprinkler system did not comply with NFPA 13. No sprinkler head existed at surgical department's janitor closet. It appeared that no sprinkler head existed at riser room.

Based on observations during the survey walk of the facility on the morning of 6/14/2017 with the Director of Supply Services, the facility failed to maintain the fire alarm system. Escutcheon plate was missing at electrical closet, OB wing's clean utility and 2 in lab department.

Based on observations during the survey walk of the facility on the morning of 6/14/2017 with the Director of Supply Services, fire extinguisher was sitting on ground in physical therapy's storage closet.
NFPA 10: ... Fire extinguishers having a gross weight not exceeding 40 pounds shall be installed so that the top of the fire extinguisher is not more than 5 feet above the floor. Fire extinguishers having a gross weight greater than 40 pounds shall be so installed so that the top of the fire extinguisher is not more than 3.5 feet above the floor.

Based on observations during the survey walk of the facility on the morning of 6/14/2017 with the Director of Supply Services, the facility's air pressurization of support rooms did not comply with state regulations. Outpatient department's clean utility was negative and its medication room was neutral. North wing's soiled utility was positive. Please verify that support spaces in patient treatment areas are correctly pressurized. Janitor and soiled rooms shall be negatively pressurized. Clean and medication rooms shall be positively pressurized.

Based on observations during the survey walk of the facility on the morning of 6/14/2017 with the Director of Supply Services, the facility failed to provide proper fire drills. Although the facility was conducting fire drills, the facility did not have a log of those in attendance of the drill.

Based on observations during the survey walk of the facility on the morning of 6/14/2017 with the Director of Supply Services, the facility failed to assure that the essential electrical system was in full compliance. Circuit 20 powered intermediate care lights from the life safety panel. Lights should be powered from the critical branch panel or a different panel other than life safety.
The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. communication systems, where used for issuing instruction during emergency conditions; 5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.



Based on observations during the survey walk of the facility on the morning of 6/14/2017 with the Director of Supply Services, the facility failed to maintain the type 1 essential electrical system. Flex conduit entered into Life Safety panel of the Type 1 essential electrical system. NFPA 70 requires .... The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable.