HospitalInspections.org

Based on observation the facility failed to provide adequate smoke barrier.

The inspector observed, while accompanied by The CEO, The Registered Nurse, and The Maintenance manager during the hours of the inspection from 1:00 PM to 3:00 PM on 05/20/2015 that there was the following issues:

A.)There was missing fire rated sealant/ caulking missing at the above ceiling of the fire rate and smoke barrier partitions.
B) While performing the fire alarm testing the cross corridor door located at the smoke barrier partition were not fully closed.

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

The inspector observed, while accompanied by The CEO, The Registered Nurse, and The Maintenance manager during the hours of the inspection from 1:00 PM to 3:00 PM on 05/20/2015 that there was the following issues:


A.) There were vehicles parked within 10 feet of the bulk oxygen tank enclosure.
B.) There was no screen or cover over the top of the medical gas cylinders against continuous exposure to direct rays of the sun.

" The minimum distance from any bulk oxygen system to any public sidewalk or parked vehicle shall be 10 ft. " - NFPA 50, 2001, 2.2.12.

" Special Precautions - Storage of Cylinders and Containers. Cylinders stored in the open shall be protected as follows: (1) Against extremes of weather and from the ground beneath to prevent rusting, (2) During winter, against accumulation of ice or snow, and (3) In summer, screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail. " - NFPA 99, 2002: 5.1.13.5.

The inspector observed, while accompanied by The CEO, The Registered Nurse, and The Maintenance manager during the hours of the inspection from 1:00 PM to 3:00 PM on 05/20/2015 that there was the following issues:



1) The Biomedical electrical semi-annual and annual inspection were overdue.
2) The Grounding system testing at inpatient areas on TDSHS form were not performed.
3) The letters indicating preferred customer status report in case of emergency situation for water and fuel source was not available.

The inspector observed, while accompanied by The CEO, The Registered Nurse, and The Maintenance manager during the hours of the inspection from 1:00 PM to 3:00 PM on 05/20/2015 that there was the following issues:

A.) At the generator set location there was a missing electrical outlet powered from the life safety branch.
B.) There no labels provided for all the emergency panels.
C.) The directories were not updated and some are missing.
D.) It is unclear if the electrical Type I system was provided for the facility due to lack of panel directories and the panel label. Type I system is required for the Hospitals. . Please provide Type I electrical system and provide three panels: Life safety branch, critical branch, and the equipment branches.
E.) The nurse call system was powered from the Life safety branch. The nurse call system shall be powered from the critical branch.

" 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 transfer switch location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

The essential electrical panels were not clearly identified. Emergency panels shall be distinctively marked so that they are readily identifiable as a component of the essential electrical system - NFPA 70, 1999 700-9(a). They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.

Emergency electric service. A type I essential electrical system shall be provided in each hospital in accordance with requirements of NFPA 99; NFPA 101, and National Fire Protection Association 110, Standard for Emergency and Standby Power Systems, 2002 edition.

Based on observation the facility failed to provide adequate smoke barrier.

The inspector observed, while accompanied by The CEO, The Registered Nurse, and The Maintenance manager during the hours of the inspection from 1:00 PM to 3:00 PM on 05/20/2015 that there was the following issues:

A.)There was missing fire rated sealant/ caulking missing at the above ceiling of the fire rate and smoke barrier partitions.
B) While performing the fire alarm testing the cross corridor door located at the smoke barrier partition were not fully closed.

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

The inspector observed, while accompanied by The CEO, The Registered Nurse, and The Maintenance manager during the hours of the inspection from 1:00 PM to 3:00 PM on 05/20/2015 that there was the following issues:


A.) There were vehicles parked within 10 feet of the bulk oxygen tank enclosure.
B.) There was no screen or cover over the top of the medical gas cylinders against continuous exposure to direct rays of the sun.

" The minimum distance from any bulk oxygen system to any public sidewalk or parked vehicle shall be 10 ft. " - NFPA 50, 2001, 2.2.12.

" Special Precautions - Storage of Cylinders and Containers. Cylinders stored in the open shall be protected as follows: (1) Against extremes of weather and from the ground beneath to prevent rusting, (2) During winter, against accumulation of ice or snow, and (3) In summer, screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail. " - NFPA 99, 2002: 5.1.13.5.

The inspector observed, while accompanied by The CEO, The Registered Nurse, and The Maintenance manager during the hours of the inspection from 1:00 PM to 3:00 PM on 05/20/2015 that there was the following issues:



1) The Biomedical electrical semi-annual and annual inspection were overdue.
2) The Grounding system testing at inpatient areas on TDSHS form were not performed.
3) The letters indicating preferred customer status report in case of emergency situation for water and fuel source was not available.

The inspector observed, while accompanied by The CEO, The Registered Nurse, and The Maintenance manager during the hours of the inspection from 1:00 PM to 3:00 PM on 05/20/2015 that there was the following issues:

A.) At the generator set location there was a missing electrical outlet powered from the life safety branch.
B.) There no labels provided for all the emergency panels.
C.) The directories were not updated and some are missing.
D.) It is unclear if the electrical Type I system was provided for the facility due to lack of panel directories and the panel label. Type I system is required for the Hospitals. . Please provide Type I electrical system and provide three panels: Life safety branch, critical branch, and the equipment branches.
E.) The nurse call system was powered from the Life safety branch. The nurse call system shall be powered from the critical branch.

" 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 transfer switch location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

The essential electrical panels were not clearly identified. Emergency panels shall be distinctively marked so that they are readily identifiable as a component of the essential electrical system - NFPA 70, 1999 700-9(a). They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.

Emergency electric service. A type I essential electrical system shall be provided in each hospital in accordance with requirements of NFPA 99; NFPA 101, and National Fire Protection Association 110, Standard for Emergency and Standby Power Systems, 2002 edition.