HospitalInspections.org

Findings: applicable to all locations
The surveyor observed, while accompanied by the facility team, during the hours of the survey from 4:30 pm - 8 pm on 3/05/24, 8:45 am - 9:15 pm on 03/06/24, and 7:30 am - 1:15 pm on 03/07/24 that there were the following issues:

1) Observed at Christus Saint Michael Health System (Texarkana, TX), level 1, 2-hour separation from clinic, there was gap at the deck which was filled with mineral wool. Verify approved construction type and method of achieving 2-hour separation.

Findings:
The surveyor observed, while accompanied by the facility team, during the hours of the survey from 4:30 pm - 8 pm on 3/05/24, 8:45 am - 9:15 pm on 03/06/24, and 7:30 am - 1:15 pm on 03/07/24 that there were the following issues:

1) Observed at Christus Saint Michael Health System (Texarkana, TX), level 6, electrical room (S659) - the required wall stenciling was painted over.

Findings:
The surveyor observed, while accompanied by the facility team, during the hours of the survey from 4:30 pm - 8 pm on 3/05/24, 8:45 am - 9:15 pm on 03/06/24, and 7:30 am - 1:15 pm on 03/07/24 that there were the following issues:

1) Observed at Christus Saint Michael Hospital (Atlanta, TX): (a) there was no emergency gas shutoff system for cooking appliances. (b) The Ansul nozzle aiming device was not pointed over the tabletop grill.
2) Observed at Christus Saint Michael Health System (Texarkana, TX), level 1 dietary - remove redundant "Emergency shut-off" signage.

Findings:
The surveyor observed, while accompanied by the facility team, during the hours of the survey from 4:30 pm - 8 pm on 3/05/24, 8:45 am - 9:15 pm on 03/06/24, and 7:30 am - 1:15 pm on 03/07/24 that there were the following issues:

1) Observed at Christus Saint Michael Rehabilitation Hospital (Texarkana, TX), there was an unsealed penetration above ceiling at the cross-corridor doors along the smoke compartment wall.

Findings:
The surveyor observed, while accompanied by the facility team, during the hours of the survey from 4:30 pm - 8 pm on 3/05/24, 8:45 am - 9:15 pm on 03/06/24, and 7:30 am - 1:15 pm on 03/07/24 that there were the following issues:

1) Based on review of the records, the temperature for the operating rooms at Christus Saint Michael Health System (Texarkana, TX) were out of range for the sampling years 2022, 2023, and persisted into January 2024 even though the acceptable temperature range per ASHRAE 170 was noted on the temperature/humidity logging sheet. Facility failed to take proactive action to bring temperature in operating rooms into compliance.

Findings:
The surveyor observed, while accompanied by the facility team, during the hours of the survey from 4:30 pm - 8 pm on 3/05/24, 8:45 am - 9:15 pm on 03/06/24, and 7:30 am - 1:15 pm on 03/07/24 that there were the following issues:

1) Observed at Christus Saint Michael Health System (Texarkana, TX), level 1, medical gas room - the vaneometer was showing this room as overly positive. This space requires negative ventilation.
2) Observed at Christus Saint Michael Health System (Texarkana, TX), level 6, mechanical room - there was leakage from the chiller pipe.
3) Observed at Christus Saint Michael Health System (Texarkana, TX), level 4, mechanical room - AHU No. 7 serving the pharmacy was not running and there was no notification to staff or out of service notice.
4) Observed at Christus Saint Michael Health System (Texarkana, TX), AHU No. 8 which served "Biomed / Food Services" had a leak and stopped running. Facility was surprised unit was down and did not receive any alarm notification.
5) Observed at Christus Saint Michael Health System (Texarkana, TX) rooftop, AHU-19 outdoor unit - the mesh screen was very dirty and needed replacement.
6) Observed at Christus Saint Michael Rehabilitation Hospital (Texarkana, TX): (a) the exhaust for the ware wash room in dietary should be located more toward the dirty side of the dish washing machine. (b) Soiled Utility (H152) had barely noticeable exhaust.
7) General Comment - provide label in large font for all the air handling units so it is easily identifiable.

Findings: applicable to all locations
The surveyor observed, while accompanied by the facility team, during the hours of the survey from 4:30 pm - 8 pm on 3/05/24, 8:45 am - 9:15 pm on 03/06/24, and 7:30 am - 1:15 pm on 03/07/24 that there were the following issues:

1) Based on review of the records, facility failed to update the EOP call list to include active employees and remove no longer employed personnel from list.

Findings:
The surveyor observed, while accompanied by the facility team, during the hours of the survey from 4:30 pm - 8 pm on 3/05/24, 8:45 am - 9:15 pm on 03/06/24, and 7:30 am - 1:15 pm on 03/07/24 that there were the following issues:

1) Observed at Christus Saint Michael Hospital (Atlanta, TX), there were dissimilar metal contacts in the mechanical room. Also, the hanger strap supporting the medical gas piping shifted off-center off the isolator tape.

Findings:
The surveyor observed, while accompanied by the facility team, during the hours of the survey from 4:30 pm - 8 pm on 3/05/24, 8:45 am - 9:15 pm on 03/06/24, and 7:30 am - 1:15 pm on 03/07/24 that there were the following issues:

1) Observed at Christus Saint Michael Hospital (Atlanta, TX), there were storage of medical gas bottles in the electrical room by the boiler area.

Findings:
The surveyor observed, while accompanied by the facility team, during the hours of the survey from 4:30 pm - 8 pm on 3/05/24, 8:45 am - 9:15 pm on 03/06/24, and 7:30 am - 1:15 pm on 03/07/24 that there were the following issues:

1) Observed at Christus Saint Michael Rehabilitation Hospital (Texarkana, TX), electrical room - the two automatic transfer switches were missing phenolic label.

Findings:
The surveyor observed, while accompanied by the facility team, during the hours of the survey from 4:30 pm - 8 pm on 3/05/24, 8:45 am - 9:15 pm on 03/06/24, and 7:30 am - 1:15 pm on 03/07/24 that there were the following issues:

1) Applicable for all locations - Based on review of the records, facility did not perform any receptacle maintenance and testing at all in patient care areas. NFPA 99-2012, section 6.3.3.2 lists the minimum requirements for receptacle testing regardless of hospital-grade or not. Describe the facility justification of testing frequency (e.g. appropriate testing intervals) based on documented performance data. For example, experiential data shows that retention force of the grounding blade of each electrical receptacle decreases over time due to repeated usage. Thus, the failure rate has a direct correlation to time and usage. What data does the facility collect or will implement that could provide the kind of indication of pending failures or reveal non-conformance receptacles such that it could take pre-emptive action before the onset of failure?

Findings:
The surveyor observed, while accompanied by the facility team, during the hours of the survey from 4:30 pm - 8 pm on 3/05/24, 8:45 am - 9:15 pm on 03/06/24, and 7:30 am - 1:15 pm on 03/07/24 that there were the following issues:

1) Observed at Christus Saint Michael Rehabilitation Hospital (Texarkana, TX) in bath tub room - the label on the electrical cover plate was fading and thus no longer legible. This is one example of many similar findings.
2) Observed at Christus Saint Michael Health System (Texarkana, TX), level 6 of south tower, pod 4 nurse station - red receptacle exhibited low retention force.
3) Observed at Christus Saint Michael Health System (Texarkana, TX), level 2 endoscopy rooms - none of the electrical receptacles were labeled.
4) Observed at Christus Saint Michael Rehabilitation Hospital (Texarkana, TX), there was no red receptacle for crash cart charging in the corridor.

Findings:
The surveyor observed, while accompanied by the facility team, during the hours of the survey from 4:30 pm - 8 pm on 3/05/24, 8:45 am - 9:15 pm on 03/06/24, and 7:30 am - 1:15 pm on 03/07/24 that there were the following issues:

1) Observed at Christus Saint Michael Hospital (Atlanta, TX), the required task light with battery backup at the generator set location was not working. It produced smoke when energized.
2) Observed at Christus Saint Michael Hospital (Atlanta, TX), there was no red receptacle connected to the Life Safety branch of the EES at the generator set location.
3) Observed at Christus Saint Michael Health System (Texarkana, TX), level 2 - electrical room next to generator had storage of rubbish.
4) Observed at Christus Saint Michael Rehabilitation Hospital (Texarkana, TX): (a) the generator was leaking coolant. (b) The light inside the generator was loose from its socket. (c) Staff did not know the purpose of circuit break no. 7 at the genset location. (d) the generator EPO was missing the tool to break glass in case of emergency.