HospitalInspections.org

North Central Baptist Hospital (building #2 on 520 Madison Oak
Based on observation the facility failed to provide proper clearance requirement at the mechanical room located on 9th floor (low headroom valve).
HLR 133.132 (d)(2)(A)(xii)(III) Overhead clearance. Suspended tracks, rails, pipes, signs, lights, door closers, exit signs, and other fixtures that protrude into the path of normal traffic shall not be less than six feet eight inches above the finished floor.



Mission Trail Baptist Hospital (building #6).
Based on observations during the tour of the facility it may not have maintained the egress route. An exit sign marked a exterior door. This door swing into the travel direction, thereby blocking the exiting pathway. Please review with local jurisdiction to determine if this is a required means of egress and the direction of swing of this door.

Baptist Medical Center (building #1 on Dallas Street),
The inspector observed, while accompanied by Safety Director, Operation Analyst, Quality Data Analyst, Facility Operation Director, Plant Manager, Life Safety Manager, and Maintenance personnel during the hours of the inspection from 09:00 AM to 11:30 AM on 06/01/2017 that there were the following issues. They were the following issues:

A) Some of the smoke barrier cross corridor doors were not fully closed located at the smoke compartment.

Mission Trail Baptist Hospital (building #6).
Based on observations during the survey walk of the facility, the facility failed to appeared not to have an exit sign marking the exit path at corridor between kitchen and surgical. Upon discussion with local jurisdiction of exiting signage, signage may be required. Also review with local jurisdiction the exit signage on second pateint floor. If required to be installed, power light from EES. NFPA 101, 2003: 7.10.1.5.1 ..... 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.

Northeast Baptist Hospital (building #3 on 8811 Village Drive)
The inspector observed, while accompanied by the Plant Manager, during the hours of the inspection from 1:00 pm to 4:30 pm on 5/29/17 that there were the following issues. In the ambulatory building's electrical room there were some pipes penetrating the rated gypsum walls that needed to be sealed.
''Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device.'' - NFPA 101, 2012, 8.3.5.1.



North Central Baptist Hospital (building #2 on 520 Madison Oak)
Based on observation the facility failed to provide adequate support for low voltage wires above ceiling at 5th floor between smoke compartment 5a and 5b near column line D. Verify all low voltage wires are properly secure..... Bundle, secure, and support all low-voltage and signal wiring, cable, pneumatic tubing, fiber optics, etc. above the ceiling.
NFPA 70,: 300-11(a)



North Central Baptist Hospital (building #2 on 520 Madison Oak),
The inspector observed, while accompanied by the Plant Manager, during the hours of the inspection from 1:00 pm to 4:30 pm on 5/29/17 that there were the following issues. In the ambulatory building's electrical room there were some pipes penetrating the rated gypsum walls that needed to be sealed.
''Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device.'' - NFPA 101, 2012, 8.3.5.1.

Baptist Medical Center (building #1 on Dallas Street),
The inspector observed, while accompanied by Safety Director, Operation Analyst, Quality Data Analyst, Facility Operation Director, Plant Manager, Life Safety Manager, and Maintenance personnel during the hours of the inspection from 09:00 AM to 11:30 AM on 06/01/2017 that there were the following issues. They were the following issues:
A.) The Pipes, conduits, bus ducts, cables, wires, and air supply ducts penetration was not sealed or fire sealed at all fire partitions located at the electrical room and the boiler room. NFPA 101, 2003: 8.3.5.1- Penetrations in fire barriers by pipes, conduits, cables, wires, bus ducts, trays, pneumatic controls, pneumatic transit tubes, and similar building services, shall be sealed with a material, or protected with a device, that is capable of preventing the passage of smoke and products of combustion, to maintain the required fire/smoke resistance of the barrier.


St. Luke's Baptist Hospital (building #5).
A. Location: LEVEL 1 - at CORRIDOR side of the PULMINARY FUNCTION LAB:
Where wall was required to be 1 hour fire-rated - there were multiple unsealed electrical conduits penetrations at the rated wall, along with stenciling which incorrectly identified the wall as only "SMOKE RATED."

B. Location: LEVEL 1 - at ROOM side of the PULMINARY FUNCTION LAB - all 4 walls were required to be 1 hour fire-rated walls, and all 4 walls had deficiencies:
" The north wall was missing the tape embedment.
" The south wall had a round duct penetration at a rectangular drywall opening which was unsealed.
" All four walls contained unsealed penetrations and / or openings.

St. Luke's Baptist Hospital (building #5).
A. Location: LEVEL 3 - near 2 hour fire-rated chase and near PATIENT BEDROOM #305:
1 hour fire/smoke barrier wall did not provide a continuous and uninterrupted membrane where top of wall met with bottom of concrete structural beam. Incomplete gypsum board coverage created multiple openings immediately below the beam. These openings in the gypsum board membranes violate the integrity of the rated partition.

C. Location: LEVEL 3 - above cross-corridor doors near PATIENT BEDROOM #305:
Numerous types and locations of "unsealed" penetrations, and improperly sealed penetrations were found. Additionally, the required fire-rated sealant was missing along the top of the rated partition where it meets with bottom of structural beam.

D. Location: LEVEL 3 - near ADL TRAINING BATHROOM:
This area appeared to have a deficiency due to improper and inadequate means of construction. A single layer of gypsum board was mounted "horizontally" to close the gap between the 1 hour fire/smoke barrier wall (primary component) and an adjacent, parallel structural concrete beam (secondary component) located just inches away from the face of the barrier wall. There was missing tape embedment, and missing fire-rated sealant. The horizontal construction assembly did not appear to be compliant with rated construction requirements.
As was discussed on-site, the facility will need to investigate, validate and document to what "partial level of completion" the "primary component" was built. Once that level of completion has been determined, then the facility should document how the integrity for the fire/smoke rating for this partition assembly has been, or will need to be completed.

Northeast Baptist Hospital (building #3 on 8811 Village Drive)
The inspector observed, while accompanied by the Plant Manager, during the hours of the inspection from 1:00 pm to 4:30 pm on 5/29/17 that there were the following issues. In the ambulatory building, there were a set of smoke double doors that did not align properly when they were closed.
''Rabbets, bevels, or astragals shall be required at the meeting edges, and stops shall be required at the head and sides of door frames in smoke barriers. Positive latching hardware shall not be required. Center mullion shall be prohibited.'' - NFPA 101, 2003: 18.3.7.10



North Central Baptist Hospital (building #2 on 520 Madison Oak)
The inspector observed, while accompanied by the Plant Manager, during the hours of the inspection from 1:00 pm to 4:30 pm on 5/29/17 that there were the following issues. In the ambulatory building, there were a set of smoke double doors that did not align properly when they were closed.
''Rabbets, bevels, or astragals shall be required at the meeting edges, and stops shall be required at the head and sides of door frames in smoke barriers. Positive latching hardware shall not be required. Center mullion shall be prohibited.'' - NFPA 101, 2003: 18.3.7.10

North Central Baptist Hospital (building #2 on 520 Madison Oak)
Based on observation the facility failed to provide proper labeling on the ER smoke compartment wall.
All fire walls, fire barriers, fire partitions, smoke barriers, and smoke partitions shall be effectively and permanently identified with signs or stenciling per IBC 2012 section 703.7.

Northeast Baptist Hospital (building #3 on 8811 Village Drive)
The inspector observed, while accompanied by the Plant Manager, during the hours of the inspection from 1:00 pm to 4:30 pm on 5/29/17 that there were the following issues. In the medical gas storage room, some medical gas cylinders were being secured by chains three at a time. Interpretation of the following code requirement has be interpreted to mean no more than two cylinders per section of chain.
''Design and Construction. Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements: (7) They shall be provided with racks, chains, or other fastening to secure all cylinders from falling, whether connected, unconnected, full, or empty.'' - NFPA 99, 2012: 5.1.3.3.2



North Central Baptist Hospital (building #2 on 520 Madison Oak)
The inspector observed, while accompanied by the Plant Manager, during the hours of the inspection from 1:00 pm to 4:30 pm on 5/29/17 that there were the following issues. In the medical gas storage room, some medical gas cylinders were being secured by chains three at a time. Interpretation of the following code requirement has be interpreted to mean no more than two cylinders per section of chain.
''Design and Construction. Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements: (7) They shall be provided with racks, chains, or other fastening to secure all cylinders from falling, whether connected, unconnected, full, or empty.'' - NFPA 99, 2012: 5.1.3.3.2

Northeast Baptist Hospital (building #3 on 8811 Village Drive)
The inspector observed, while accompanied by the Plant Manager, during the hours of the inspection from 1:00 pm to 4:30 pm on 5/29/17 that there were the following issues.

Main emergency electrical generator. Inside the generator, there was a large electrical j-box that was missing its cover.

The main transfer switch room was being used for storage of tools and materials which partially blocked the clear area in front of the electrical panels.
''Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.'' - NFPA 70, 2011, 110.26(B)

The inspector observed, while accompanied by the Plant Manager, during the hours of the inspection from 9:00 am to 11:30 am on 5/30/17 that there were the following issues. The tower-4th floor. The electrical room was being used to store a ladder, which blocked clear access to a electrical panel.


St. Luke's Baptist Hospital (building #5).
A. Location: WOMEN'S CENTER GENERATOR.
There was no Gen Set containing the required electrical receptacle / light for the generator. These must be circuited on the LIFE SAFETY BRANCH, and the light must be provided a charger and battery capable of providing 90 minutes of service.



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Baptist Medical Center (building #1 on Dallas Street),
The inspector observed, while accompanied by Safety Director, Operation Analyst, Quality Data Analyst, Facility Operation Director, Plant Manager, Life Safety Manager, and Maintenance personnel during the hours of the inspection from 2 pm to 6 pm on 05/31/2017 and from 09:00 AM to 11:30 AM on 06/01/2017 that there were the following issues. They were the following issues.

A.) There were some J-boxes missing its cover and labeling at the Electrical room and Boiler room.

Northeast Baptist Hospital (building #3 on 8811 Village Drive)
The inspector observed, while accompanied by the Plant Manager, during the hours of the inspection from 1:00 pm to 4:30 pm on 5/29/17 that there were the following issues. In the ambulatory building's operating room and on the x-ray room's booms there were some critical care receptacles that needed to be permanently labeled per the following requirements.
''Critical Care Areas: Patient Bed Location Branch Circuits. Each patient bed location shall be supplied by at least two branch circuits, one or more from the emergency system and one or more circuits from the normal system. At least one branch circuit from the emergency system shall supply an outlet(s) only at that bed location. All branch circuits from the normal system shall be from a single panel board. Emergency System receptacles shall be identified and shall also indicate the panelboard and circuit number supplying them.'' NFPA 70, 2002, 517.19(A).
The inspector observed, while accompanied by the Plant Manager, during the hours of the inspection from 9:00 am to 11:30 am on 5/30/17 that there were the following issues. The Tower - 3rd Floor - There were some critical care receptacles that needed to be permanently labeled per the previous requirements.



North Central Baptist Hospital (building #2 on 520 Madison Oak),
The inspector observed, while accompanied by the Plant Manager, during the hours of the inspection from 1:00 pm to 4:30 pm on 5/29/17 that there were the following issues. In the ambulatory building's operating room and on the x-ray room's booms there were some critical care receptacles that needed to be permanently labeled per the following requirements.
''Critical Care Areas: Patient Bed Location Branch Circuits. Each patient bed location shall be supplied by at least two branch circuits, one or more from the emergency system and one or more circuits from the normal system. At least one branch circuit from the emergency system shall supply an outlet(s) only at that bed location. All branch circuits from the normal system shall be from a single panel board. Emergency System receptacles shall be identified and shall also indicate the panelboard and circuit number supplying them.'' NFPA 70, 2002, 517.19(A).
The inspector observed, while accompanied by the Plant Manager, during the hours of the inspection from 9:00 am to 11:30 am on 5/30/17 that there were the following issues. The Tower - 3rd Floor - There were some critical care receptacles that needed to be permanently labeled per the previous requirements.

Baptist Medical Center (building #1 on Dallas Street),
The inspector observed, while accompanied by Safety Director, Operation Analyst, Quality Data Analyst, Facility Operation Director, Plant Manager, Life Safety Manager, and Maintenance personnel during the hours of the inspection from 2 pm to 6 pm on 05/31/2017 and from 09:00 AM to 11:30 AM on 06/01/2017 that there were the following issues. They were the following issues.


A.) There labels provided for some of the electrical panels and the essential transfer switches were not readily identifiable to identify life safety, critical and equipment branch. NFPA 70, 2002: 110-22 and 700-9(a). - "Emergency panels shall be distinctively marked so that they are readily identifiable as a component of the essential electrical system." - They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.

North Central Baptist Hospital (building #2 on 520 Madison Oak
Based on observation the facility failed to provide proper emergency panel location for the nurse call system located on the 3rd floor (circuit currently located at Life Safety Panel).
The nurse call system shall be on the critical branch of the emergency electrical system - NFPA 70, 517.33 (A)(5).

North Central Baptist Hospital (building #2 on 520 Madison Oak
Based on observation the facility failed to provide proper emergency panel location for the nurse call system located on the 1st floor.
When labeled, comply with NFPA 70, 2002: 408.4..... All circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel door in the case of a panelboard, and at each switch on a switchboard.

North Central Baptist Hospital (building #2 on 520 Madison Oak
Based on observation the facility failed to provide adequate marking for emergency panels located on the 3rd floor of the 1991 built bldg. at NE corner......"Emergency panels shall be distinctively marked so that they are readily identifiable as a component of the essential electrical system." - NFPA 70, 2002: 110-22 and 700-9(a). They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.


Northeast Baptist Hospital (building #3 on 8811 Village Drive)
Based on observation, the facility failed to properly annunciate the nurse call. The nurse call did not signal the dome light at imaging's corridor, which faced the nurse station, when the patient toilet was rang in two imaging rooms. The storage room did not have a nurse call staff station (duty station). Additionally verify that the duty station in both soiled and clean in the emergency department alarms when any imaging department's nurse call is activated. This is because the soiled and clean workrooms are shared by both the emergency and imaging departments, but they are located in the emergency department's suite.

Northeast Baptist Hospital (building #3 on 8811 Village Drive)
The inspector observed, while accompanied by the Plant Manager, during the hours of the inspection from 1:00 pm to 4:30 pm on 5/29/17 that there were the following issues. In the major plant room, there was a copper gas line in contact with a support angle made dissimilar metal.
'''Copper medical gas piping shall be separated or insulated from dissimilar metal piping and supports to prevent bimetallic electrolyte action.'' - NFPA 99, 2002: 5.1.10.6.4



North Central Baptist Hospital (building #2 on 520 Madison Oak)
The inspector observed, while accompanied by the Plant Manager, during the hours of the inspection from 1:00 pm to 4:30 pm on 5/29/17 that there were the following issues. In the major plant room, there was a copper gas line in contact with a support angle made dissimilar metal.
'''Copper medical gas piping shall be separated or insulated from dissimilar metal piping and supports to prevent bimetallic electrolyte action.'' - NFPA 99, 2002: 5.1.10.6.4

Baptist Medical Center (building #1 on Dallas Street),
The inspector observed, while accompanied by Safety Director, Operation Analyst, Quality Data Analyst, Facility Operation Director, Plant Manager, Life Safety Manager, and Maintenance personnel during the hours of the inspection from 2 pm to 6 pm on 05/31/2017 and from 09:00 AM to 11:30 AM on 06/01/2017 that there were the following issues. They were the following issues.


A) There were not an insolation between the metal hanger supports and the copper medical gas pipes at the Mechanical room and above ceiling at the control cross corridor doors. NFPA 99, 2002: 5.1.10.6.4 - "Copper piping shall be separated or insulated from dissimilar metal piping and supports to prevent bimetallic electrolyte action."