HospitalInspections.org

Based on observation the facility failed to provide a complete sprinkler system.

The inspector observed, while accompanied by the CEO, Chief Nursing Officer, Director of Human Resource, and the Building Engineer during the hours of the inspection from 3:30 pm to 5:30 pm on 11/05/2013 that there were the following issues.

A.) There were missing sprinkler head at the following locations: 1) mechanical room under ducts larger than 4 feet wide.

B.) There were missing escutcheon plates at the following locations: 1) Administration Offices.

Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors. - NFPA 13, 1999, 5-5.5.3.1.

Escutcheons are part of the listed assembly per 1999 NFPA 13 ?3-2.7.2.

Based on observation the facility failed to provide adequate medical gas system.

The inspector observed, while accompanied by the CEO, Chief Nursing Officer, Director of Human Resource, and the Building Engineer during the hours of the inspection from 3:30 pm to 5:30 pm on 11/05/2013 that there were the following issues.


A.) Based on observation the facility failed to provide individual chains for the medical gases bottles. This does not comply with the following NFPA code. " Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. " - NFPA 99, 1999: 4-3.1.1.1.

B.) There was no signage provided at the Med Gas storage door.

CAUTION
Medical Gases
NO Smoking or Open Flame

See NFPA 99, 2002: 5.1.3.1.6.

C.) The med gas cylinders stored in the open was not protected.

See NFPA 99, 2002: 5.1.3.5.4.Cylinder stored in the open shall be protected to against extreme of weather and from the ground beneath to prevent rusting, against accumulation of ice or snow, screened against continuous exposure to direct ray of sun in those localities where extreme temperature prevail.

Based on observation the facility failed to provide adequate receptacles and battery powered lighting units .

The inspector observed, while accompanied by the CEO, Chief Nursing Officer, Director of Human Resource, and the Building Engineer during the hours of the inspection from 3:30 pm to 5:30 pm on 11/05/2013 that there were the following issues.

(1). There was a missing battery powered lighting units at the essential automatic transfer switch at the electrical room and at the generator set location. (2). There was a missing battery powered lighting units and a missing receptacle powered from life safety branch at the essential automatic transfer switch and at the generator set location.

" The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location and essential automatic transfer switch location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

Based on observation the facility failed to provide the Grounding system report for inpatient care areas and the Line Isolation Monitor Tests report on TDSHS form. This is required of all hospitals.

The inspector observed, while accompanied by the CEO, Chief Nursing Officer, Director of Human Resource, and the Building Engineer during the hours of the inspection from 3:30 pm to 5:30 pm on 11/05/2013 that there were the following issues.

A) The facility failed to provide a history of records for receptacle testing at inpatient care areas and the Line Isolation Monitor per NFPA 99: 3-3.3.3. in patient care areas.

" Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). "

" NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, ?133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984). "

Based on observation the facility failed to provide a complete sprinkler system.

The inspector observed, while accompanied by the CEO, Chief Nursing Officer, Director of Human Resource, and the Building Engineer during the hours of the inspection from 3:30 pm to 5:30 pm on 11/05/2013 that there were the following issues.

A.) There were missing sprinkler head at the following locations: 1) mechanical room under ducts larger than 4 feet wide.

B.) There were missing escutcheon plates at the following locations: 1) Administration Offices.

Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors. - NFPA 13, 1999, 5-5.5.3.1.

Escutcheons are part of the listed assembly per 1999 NFPA 13 ?3-2.7.2.

Based on observation the facility failed to provide adequate medical gas system.

The inspector observed, while accompanied by the CEO, Chief Nursing Officer, Director of Human Resource, and the Building Engineer during the hours of the inspection from 3:30 pm to 5:30 pm on 11/05/2013 that there were the following issues.


A.) Based on observation the facility failed to provide individual chains for the medical gases bottles. This does not comply with the following NFPA code. " Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. " - NFPA 99, 1999: 4-3.1.1.1.

B.) There was no signage provided at the Med Gas storage door.

CAUTION
Medical Gases
NO Smoking or Open Flame

See NFPA 99, 2002: 5.1.3.1.6.

C.) The med gas cylinders stored in the open was not protected.

See NFPA 99, 2002: 5.1.3.5.4.Cylinder stored in the open shall be protected to against extreme of weather and from the ground beneath to prevent rusting, against accumulation of ice or snow, screened against continuous exposure to direct ray of sun in those localities where extreme temperature prevail.

Based on observation the facility failed to provide adequate receptacles and battery powered lighting units .

The inspector observed, while accompanied by the CEO, Chief Nursing Officer, Director of Human Resource, and the Building Engineer during the hours of the inspection from 3:30 pm to 5:30 pm on 11/05/2013 that there were the following issues.

(1). There was a missing battery powered lighting units at the essential automatic transfer switch at the electrical room and at the generator set location. (2). There was a missing battery powered lighting units and a missing receptacle powered from life safety branch at the essential automatic transfer switch and at the generator set location.

" The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location and essential automatic transfer switch location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

Based on observation the facility failed to provide the Grounding system report for inpatient care areas and the Line Isolation Monitor Tests report on TDSHS form. This is required of all hospitals.

The inspector observed, while accompanied by the CEO, Chief Nursing Officer, Director of Human Resource, and the Building Engineer during the hours of the inspection from 3:30 pm to 5:30 pm on 11/05/2013 that there were the following issues.

A) The facility failed to provide a history of records for receptacle testing at inpatient care areas and the Line Isolation Monitor per NFPA 99: 3-3.3.3. in patient care areas.

" Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). "

" NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, ?133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984). "