HospitalInspections.org

Based on observations during the tour of the facility on 10/11/2018, with the Director of Engineering and Safety Officer, the facility failed to maintain the exits.
EXIT sign was missing at end of corridor, near dining. Therefore the egress path was not marked.
"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." - NFPA 101, 2003: 7.10.1.5.1

Based on observations during the tour of the facility on 10/11/2018, with the Director of Engineering and Safety Officer, the facility failed to maintain the rooms as designated on initial plans.
Patient room TC 201 was used as director of nursing. First floor's outpatient department was using one the exam rooms as a pubic lounge. Cath lab holding area did not meet the requirements of number of receptacles and medical gases per licensing rules. This holding area is not required for these rooms, since more recent holding spaces have been constructed.
"The maximum design bed capacity includes beds that comply with the requirements in §133.163 of this title even if the beds are unoccupied or the space is used for other purposes such as offices or storage rooms, provided such rooms can readily be returned to patient use. All required support and service areas must be maintained in place. For example, the removal of a nurse station in an unused patient bedroom wing of 20 beds would effectively eliminate those 20 beds from the design capacity. Eliminating access to the medical gas outlets and nurse call would also remove bed(s) from the design capacity." - HLR §133.26 (a)(1)(B)



Based on observations during the tour of the facility on 10/11/2018, with the Director of Engineering and Safety Officer, the facility failed to maintain the building.
Hole existed at first floor's mechanical room M-103 exterior wall, near dietary. End caps were missing at the ceiling at imaging rooms' unistrut rail. Confirm all unistruts have end caps.
"Floor, wall and ceiling penetrations by pipes, ducts, and conduits or any direct opening 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)




Based on observations during the tour of the facility on 10/11/2018, with the Director of Engineering and Safety Officer, the facility failed to inform the state of remodel within the faciltiy.
Operating room was being remodeled and elevator was being added. If any construction occurs in a licensed hospital, then facility shall make a project with the Health and Human Service's Architectural Review Group. Attached is a minor project application to fill out. Fax to 512-834-6620 the completed minor project application along with a floor plan and a narrative describing the work being done.
"Hospital owners/operators may not begin construction of a new building, additions to or renovations or conversions of existing buildings until the department approves final construction documents." - HLR §133.167 (a)(1)

Based on observations during the tour of the facility on 10/11/2018, with the Director of Engineering and Safety Officer, the facility failed to maintain the rated partition.
Rated doors did not latch at storage room at surgical department's sub sterile (2 doors in this room) and also pre-op's soiled utility room. Lab storage door was not kept shut.
"Unless otherwise specified, fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8." NFPA 101; 2012: 8.3.3.3

Based on observations during the tour of the facility on 10/11/2018, with the Director of Engineering and Safety Officer, the facility failed to provide adequate locations for alcohol-based hand-rub dispensers (ABR).
Alcohol based hand rub was located over an ignition source (light switch) at surgical department's soiled room and lab storage, near imaging department and at imaging department's two CT scan rooms.
"Dispensers shall not be installed in the following locations: (a)?Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source." - NFPA 101: 2012 18.3.2.6* (8)

Based on observations during the tour of the facility on 10/11/2018, with the Director of Engineering and Safety Officer, the facility failed to maintain the safety of the egress corridor.
Corridor door did not latch at second floor's ICU 2201.
"Corridor walls shall form a barrier to limit the transfer of smoke." - NFPA 101; 2003: 18.3.6.2.3*

Based on observations during the tour of the facility on 10/11/2018, with the Director of Engineering and Safety Officer, the facility failed to provide complaint smoke compartment doors.
Vision panels were missing at smoke barrier's doors, near 2306. This condition also occurred at each patient floor 3-5, stacked above the second floor's smoke barrier at the end of the patient wing. Ensure all smoke compartment doors have view windows.
"Vision panels consisting of fire-rated glazing in approved frames shall be provided in each cross-corridor swinging door and at each cross-corridor horizontal-sliding door in a smoke barrier." - NFPA 101; 2012: 18.3.7.9
"cross-corridor control doors shall consist of ..... Each door leaf shall be provided with a view window." - HLR 2007: §133.162 (d)(2)(A)(vii)

Based on observations during the tour of the facility on 10/11/2018, with the Director of Engineering and Safety Officer, the facility failed to maintain the isolation room.
Closure was missing at second floor's anteroom.
"A door(s) from an anteroom to an airborne infection isolation room(s) and a door(s) from an egress corridor into an anteroom shall be provided with a self-closing device(s). When an isolation room does not have an anteroom, the door from the egress corridor into the isolation room shall be provided with a self-closing device." - HLR: §133.163 (t)(1)(C)(iv)



Based on observations during the tour of the facility on 10/11/2018, with the Director of Engineering and Safety Officer, the facility failed to maintain the cleanliness of the air.
Return air grill was filthy at blood lab. In addition to cleaning the grill, please explain the cause.
"Physical environment. A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each hospital." - §133.162 (d)(1)(A)



Based on observations during the tour of the facility on 10/11/2018, with the Director of Engineering and Safety Officer, the facility failed to provide nurse call.
Nurse call duty station was missing at Pre-op's clean utility room.
"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." - HLR, 2007: Figure: 25 TAC §133.169 (g), Table 7.

Based on observations during the tour of the facility on 10/11/2018, with the Director of Engineering and Safety Officer, the facility failed to maintain air pressure of a dirty room.
Ware wash was not a room, it was opened to the kitchen since its original door was removed from its frame.
In addition to addition of a door, ware wash room was neutrally pressurized to kitchen but should be negatively pressurized.
"Ware washing room. A ware washing room equipped with commercial type dishwasher equipment shall be located separate from the food preparation and serving areas. Space shall be provided for receiving, scraping, sorting, and stacking soiled tableware and for transferring clean tableware to the using areas. Hand washing facilities with hands-free operable controls shall be located within the soiled dish wash area. A physical separation to prevent cross-traffic between "dirty side" and "clean side" of the dish wash areas shall be provided." HLR: §133.163(e)(1)(B)(viii)
HLR: Figure: 25 TAC §133.169 (c), Table 3.

Based on observations during the tour of the facility on 10/11/2018, with the Director of Engineering and Safety Officer, the facility did not remove copper piping.
Long pieces of copper piping existed at first floor's mechanical rooms, near dietary. Remove all unused copper piping, so that it cannot be used for medical gas.