HospitalInspections.org

Findings:
The inspector observed, while accompanied by the Regional Director Risk Management, Vice President, Administrative Director, System Facility Director, Chief Building Engineer, Manager of Security, Regional Facility Manager, and Plant Services Building Engineer, during the hours of the inspection from 12:30 PM to 4:30 PM on 01/04/2018, from 12:45 PM to 4 PM on 01/05/2018, from 12:30 PM to 4:30 PM on 01/09/2018, from 9 AM to 4 PM on 01/10/2018, and from 9 AM to 11 AM on 01/11/2018 that there were the following issues:
1) Observed in Christus Southeast Texas Outpatient Center Mid-County. The kitchen dishwasher was a not a true pass through type. A pass-through only allows a person on dirty side to fill the dishwasher and then when dishes are clean, the employee on the clean side pulls out the tray. If the dishwasher specified via cut sheets, then it must be modified with a permanent front panel that prevents access to the dishes from the front of the machine when the door is raised. Thus it would effectively create a pass through design that meets rules, although the 'pass through' is preferred.
2) Observed in Christus Southeast Texas St. Elizabeth main campus. On the 3rd floor endoscopy room number 2, there were unistruts in the ceiling with missing endcaps. Per Hospital Licensing Rules ...Floor, wall and ceiling penetrations by pipes, ducts, and conduits or any direct openings shall be tightly sealed to minimize entry of dirt particles, rodents and insects. Joints of structural elements shall be similarly sealed. - HLR, 2007, §133.162 (d)(2)(B)(v).
3) Observed in Outpatient Pavilion Building 1st floor near shipping/receiving dock. The door to the fire riser room did not have signage.
4) Observed in Outpatient Pavilion operating rooms. There were cracks in the monolithic flooring near the leg supporting the computer desk.

Findings:
The inspector observed, while accompanied by the Regional Director Risk Management, Vice President, Administrative Director, System Facility Director, Chief Building Engineer, Manager of Security, Regional Facility Manager, and Plant Services Building Engineer, during the hours of the inspection from 12:30 PM to 4:30 PM on 01/04/2018, from 12:45 PM to 4 PM on 01/05/2018, from 12:30 PM to 4:30 PM on 01/09/2018, from 9 AM to 4 PM on 01/10/2018, and from 9 AM to 11 AM on 01/11/2018 that there were the following issues:
1) Observed in Christus Southeast Texas St. Mary's campus - Central Plant building. The door to the carpentry shop did not have automatic door closer.

Findings:
The inspector observed, while accompanied by the Regional Director Risk Management, Vice President, Administrative Director, System Facility Director, Chief Building Engineer, Manager of Security, Regional Facility Manager, and Plant Services Building Engineer, during the hours of the inspection from 12:30 PM to 4:30 PM on 01/04/2018, from 12:45 PM to 4 PM on 01/05/2018, from 12:30 PM to 4:30 PM on 01/09/2018, from 9 AM to 4 PM on 01/10/2018, and from 9 AM to 11 AM on 01/11/2018 that there were the following issues:
1) Observed in Christus Southeast Texas St. Mary's campus - Central Plant building and St. Elizabeth's campus - Central Plant 1st floor. At the exit discharge there were no exit signs with continuous illumination served by the emergency lighting system.

Findings:
The inspector observed, while accompanied by the Regional Director Risk Management, Vice President, Administrative Director, System Facility Director, Chief Building Engineer, Manager of Security, Regional Facility Manager, and Plant Services Building Engineer, during the hours of the inspection from 12:30 PM to 4:30 PM on 01/04/2018, from 12:45 PM to 4 PM on 01/05/2018, from 12:30 PM to 4:30 PM on 01/09/2018, from 9 AM to 4 PM on 01/10/2018, and from 9 AM to 11 AM on 01/11/2018 that there were the following issues:
1) Observed in Christus Southeast Texas St. Elizabeth's campus - main hospital 3rd floor "specimen room." There was a smoke detector covered with duct tape. This item was observed as corrected by the Life Safety Code Surveyor.

Findings:
The inspector observed, while accompanied by the Regional Director Risk Management, Vice President, Administrative Director, System Facility Director, Chief Building Engineer, Manager of Security, Regional Facility Manager, and Plant Services Building Engineer, during the hours of the inspection from 12:30 PM to 4:30 PM on 01/04/2018, from 12:45 PM to 4 PM on 01/05/2018, from 12:30 PM to 4:30 PM on 01/09/2018, from 9 AM to 4 PM on 01/10/2018, and from 9 AM to 11 AM on 01/11/2018 that there were the following issues:
1) Observed in Christus Southeast Texas St. Elizabeth's campus - Central Plant 1st floor, generator No. 1 room. There were sprinkler heads that had appearance of rust and dust.
2) Observed in Christus Southeast Texas St. Elizabeth's campus - main building first floor dietary suite. Inside freezer D and refrigerator B, the sprinkler escutcheon covers were loose. Also the sprinkler heads had appearance of rust.

Findings:
The inspector observed, while accompanied by the Regional Director Risk Management, Vice President, Administrative Director, System Facility Director, Chief Building Engineer, Manager of Security, Regional Facility Manager, and Plant Services Building Engineer, during the hours of the inspection from 12:30 PM to 4:30 PM on 01/04/2018, from 12:45 PM to 4 PM on 01/05/2018, from 12:30 PM to 4:30 PM on 01/09/2018, from 9 AM to 4 PM on 01/10/2018, and from 9 AM to 11 AM on 01/11/2018 that there were the following issues:
1) Observed in Christus Southeast Texas St. Elizabeth's campus - Outpatient Pavilion, 2nd floor mechanical room. This room was used to store stretchers and recliners, which in two instances, blocked access path to the fire extinguishers.

Findings:
The inspector observed, while accompanied by the Regional Director Risk Management, Vice President, Administrative Director, System Facility Director, Chief Building Engineer, Manager of Security, Regional Facility Manager, and Plant Services Building Engineer, during the hours of the inspection from 12:30 PM to 4:30 PM on 01/04/2018, from 12:45 PM to 4 PM on 01/05/2018, from 12:30 PM to 4:30 PM on 01/09/2018, from 9 AM to 4 PM on 01/10/2018, and from 9 AM to 11 AM on 01/11/2018 that there were the following issues:
1) Observed in Christus Southeast Texas St. Mary's campus - south building, 4th floor. There was an unsealed penetration above the cross-corridor doors. This item was observed as corrected by the Life Safety Code Surveyor.

Findings:
The inspector observed, while accompanied by the Regional Director Risk Management, Vice President, Administrative Director, System Facility Director, Chief Building Engineer, Manager of Security, Regional Facility Manager, and Plant Services Building Engineer, during the hours of the inspection from 12:30 PM to 4:30 PM on 01/04/2018, from 12:45 PM to 4 PM on 01/05/2018, from 12:30 PM to 4:30 PM on 01/09/2018, from 9 AM to 4 PM on 01/10/2018, and from 9 AM to 11 AM on 01/11/2018 that there were the following issues:
1) Observed in Christus Southeast Texas St. Elizabeth's campus - main building, 1st floor mechanical room, located next to laboratory. There was a large rectangular opening, approximately 1' x 2' opening in an active air duct without any screen or filter in place.
2) Observed in Christus Southeast Texas St. Elizabeth's campus - main building, 1st floor mechanical room, located next to laboratory. There was an air handling unit where the magnehelic gauge exceeded a value of 2 inches of water. Staff indicated the magnehelic device is non-operational. If such is the case, it should be repaired or the air filter be changed out.
3) General Observation. Based on interview with staff and review of records, final filters and filter frames were not visually inspected for pressure drop and for bypass on a monthly basis.

Findings:
The inspector observed, while accompanied by the Regional Director Risk Management, Vice President, Administrative Director, System Facility Director, Chief Building Engineer, Manager of Security, Regional Facility Manager, and Plant Services Building Engineer, during the hours of the inspection from 12:30 PM to 4:30 PM on 01/04/2018, from 12:45 PM to 4 PM on 01/05/2018, from 12:30 PM to 4:30 PM on 01/09/2018, from 9 AM to 4 PM on 01/10/2018, and from 9 AM to 11 AM on 01/11/2018 that there were the following issues:
1) Based on review of records, fire drills did not include transmission of a fire alarm signal. The fire drill attendance sign-in sheet did not indicate a reasonable representation of participants from the clinical staff.

Findings:
The inspector observed, while accompanied by the Regional Director Risk Management, Vice President, Administrative Director, System Facility Director, Chief Building Engineer, Manager of Security, Regional Facility Manager, and Plant Services Building Engineer, during the hours of the inspection from 12:30 PM to 4:30 PM on 01/04/2018, from 12:45 PM to 4 PM on 01/05/2018, from 12:30 PM to 4:30 PM on 01/09/2018, from 9 AM to 4 PM on 01/10/2018, and from 9 AM to 11 AM on 01/11/2018 that there were the following issues:
1) Observed in Christus Southeast Texas St. Elizabeth's campus - main building, 1st floor mechanical room, located next to laboratory. There was an electrical junction box without cover.

Findings:
The inspector observed, while accompanied by the Regional Director Risk Management, Vice President, Administrative Director, System Facility Director, Chief Building Engineer, Manager of Security, Regional Facility Manager, and Plant Services Building Engineer, during the hours of the inspection from 12:30 PM to 4:30 PM on 01/04/2018, from 12:45 PM to 4 PM on 01/05/2018, from 12:30 PM to 4:30 PM on 01/09/2018, from 9 AM to 4 PM on 01/10/2018, and from 9 AM to 11 AM on 01/11/2018 that there were the following issues:
1) Observed in Christus Southeast Texas St. Elizabeth's campus - 5 west nurse station and patient room 234. There were multiple instances where the red receptacles were held loosely to the wall outlet box.
2) Based on review of records, facility did not establish a consistent testing interval and maintain testing records for the year 2016.

Findings:
The inspector observed, while accompanied by the Regional Director Risk Management, Vice President, Administrative Director, System Facility Director, Chief Building Engineer, Manager of Security, Regional Facility Manager, and Plant Services Building Engineer, during the hours of the inspection from 12:30 PM to 4:30 PM on 01/04/2018, from 12:45 PM to 4 PM on 01/05/2018, from 12:30 PM to 4:30 PM on 01/09/2018, from 9 AM to 4 PM on 01/10/2018, and from 9 AM to 11 AM on 01/11/2018 that there were the following issues:
1) Observed in Christus Southeast Texas St. Elizabeth's campus - Orthopedic Specialty Center. No isolated power systems (e.g. line isolation monitor) were observed in any of the three operating rooms. Please develop a risk assessment and have it readily available upon request by the authority having jurisdiction.

Findings:
The inspector observed, while accompanied by the Regional Director Risk Management, Vice President, Administrative Director, System Facility Director, Chief Building Engineer, Manager of Security, Regional Facility Manager, and Plant Services Building Engineer, during the hours of the inspection from 12:30 PM to 4:30 PM on 01/04/2018, from 12:45 PM to 4 PM on 01/05/2018, from 12:30 PM to 4:30 PM on 01/09/2018, from 9 AM to 4 PM on 01/10/2018, and from 9 AM to 11 AM on 01/11/2018 that there were the following issues:
1) Observed in Christus Southeast Texas St. Mary's campus - main building. Life Safety Panel "LLS1" directory placard did not correctly cross reference with the number of breakers available. Similar observation noted for panel "LEQ1".
2) Observed in Christus Southeast Texas St. Elizabeth's campus - Outpatient Pavilion, 3rd floor operating room. Electrical panels "IP33A" and "IP33B" were missing schedule directory placard. Also, the schedule did not match the number of breakers available.