HospitalInspections.org

.

Based on observation and interview, the facility failed to maintain the two hour fire resistance-rated construction between occupancies per the requirements of:

2012 NFPA 101, 19.1.3.4.1

Findings include:

On 05/30/2018, during a tour of the facility from 7:45 am to 5:15 pm, the surveyor observed an approximately 3" unsealed penetration of two orange wires all the way through the two hour fire rated barrier on the 2nd floor by CVSU and separating the ACC POB building.

A member of the maintenance staff was present when this deficiency was identified.
.

.

Based on observation and interview, the facility failed to maintain the delayed egress signage per the requirements of:

2012 NFPA 101, 19.2.2.2.4 (2), and 7.2.1.6.1.1 (4)

Findings include:

A. On 05/29/2018, during a tour of the facility from 9:15 am to 5:00 pm, the surveyor observed the delayed egress stairwell door in IMCU 7 on the 7th floor did not have delayed egress signage.


36148


B. On 05/29/2018, during a tour of the facility from 9:15 am to 5:00 pm, the delayed egress doors located at the following locations were observed without the required signage: "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPEN IN 15 SECONDS."
1. 3rd Floor Stairway Exits
2. 4th Floor Stairway Exits
3. 5th Floor Stairway Exits
4. 6th Floor Stairway Exits

A member of the maintenance staff was present when this deficiency was identified.
.

.

Based on observation and interview, the facility failed to maintain an exit sign per the requirements of:

2012 NFPA 101, 19.2.10.1, and 7.10.2.1

Findings include:

On 05/30/2018, during a tour of the facility from 7:45 am to 5:15 pm, the surveyor observed the exit sign at stairwell 11, coming from the elevators; directs you into the Family Waiting Room across the corridor from the stairwell on the 7th floor.

A member of the maintenance staff was present when this deficiency was identified.

.

.

Based on observation and interview, the facility failed to maintain the 1 hour fire resistance rating of the elevator shaft per the requirements of:

2012 NFPA 101, 19.3.1.1

Findings include:

On 05/31/2018, during a tour of the facility from 7:45 am to 5:00 pm, the surveyor observed elevator shafts with unsealed penetrations at the sprinkler pipe and at a copper pipe in the following locations:
1. Women's Hospital 123
2. Women's Care Unit

A member of the maintenance staff was present when this deficiency was identified.

.

.

Based on observation and interview, the facility failed to maintain a hazardous room per the requirements of:

2012 NFPA 101, 19.3.2.1.3

Findings include:

On 05/29/2018, during a tour of the facility from 9:15 am to 5:00 pm, the surveyor observed the new Supply Room (old Conference Room) located across from the Nurses' Station was over 50 sq. ft. with combustibles and the door did not have a self-closing device.

A member of the maintenance staff was present when this deficiency was identified.
.

.

Based on observation and interview, the facility failed to install alcohol-based hand-rub (ABHR) dispensers per requirements of:

2012 NFPA 101, 19.3.2.6 (8)

Findings include:

On 05/29/2018, during a tour of the facility from 9:15 am to 5:00 pm, the surveyor observed ABHR dispensers were mounted directly above a light switch (ignition source) in the following locations:

1. Women's Hospital Center 5th floor room 4016
2. Women's Hospital Center 5th floor room 4031
3. PACU 1st Floor room 3 in Main Bldg
4. PACU 1st Floor room 4 in Main Bldg

A member of maintenance staff was present when this deficiency was found.
.

.

Based on observation and interview, the facility failed to maintain the fire alarm devices per the requirements of:

2012 NFPA 101, 19.3.4.1, 9.6.1.3, and 9.6.3.5
2010 NFPA 72, 14.2.1, 14.2.1.2.2, 18.4.3.5.2 and 18.5

Findings include:

A. On 05/31/2018, during a tour of the facility from 7:45 am to 5:00 pm, during the testing of the fire alarm system the surveyors observed fire alarm audio and visual devices not working at the following locations:
1. 7th floor - between the Clinical Coordinator's Office and the Medication Room
2. 7th floor - across from the Nurses' Station by the elevators at the cross corridor doors


39326


B. On 05/29/2018, during a tour of the facility from 9:15 am to 5:00 pm, during the testing of the fire alarm system the surveyors observed fire alarm visual devices not working at the following locations:
1. 6th floor - South Hall
2. Ground floor - Lab and Psych Units

C. On 05/29/2018, during a tour of the facility from 9:15 am to 5:00 pm, the surveyor observed no fire alarm visual devices in the following locations:
1. 2nd floor - CVS back hallway
2. Ground floor from Estes building to Psych Unit Hallway

A member of the maintenance staff was present when this deficiency was identified.
.

.

Based on review of documentation and interview, the facility failed to install an electronic tamper device for the automatic the sprinkler system's post indicator valve (PIV) per the requirements of:

2012 NFPA 101, 9.7.2.1*

Findings include:

On 5/30/2018, during a tour of the facility from 7:45 am to 5:15 pm, the surveyor observed a PIV outside of the Hybrid OR without a tamper device (electronic sprinkler supervision).

A member of the maintenance staff was present when this deficiency was identified.
.

.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system per the requirements of:

2012 NFPA 101, 9.7.5
2010 NFPA 25, 5.2.1.1.1, 5.2.1.1.2, and 5.2.1.1.4

Findings include:

On 05/30/2018, during a tour of the facility from 7:45 am to 5:15 pm, the surveyor observed a sprinkler head with half of the deflector broken off in the Soiled Utility Room across from rooms 251 and 253.

A member of the maintenance staff was present when this deficiency was identified.
.

.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers per the requirements of:

2012 NFPA 101, 19.3.5.12, and 9.7.4.1
2010 NFPA 10, 7.2.1.2

Findings include:

A. On 05/30/2018, during a tour of the facility from 7:45 am to 5:15 pm, the surveyor observed the following:
1. 7th floor - IMCU 7 neither portable fire extinguishers in this locked down unit were inspected during the month of April 2018.
2. 4th floor - Mechanical Room two of the portable fire extinguishers located in this space had not had a monthly inspection since January 2018.


36148


B. On 5/29/2018, during a tour of the facility from 9:15 am to 5:00 pm, the surveyor observed March, 2018 was the last monthly inspection documented on the following fire extinguishers for the Women's Hospital parking deck 1:
1. In the Elevator Room
2. Outside of the Elevator Room

A member of the maintenance staff was present when the deficiency was identified.
.

.

Based on observation and interview, the facility failed to maintain the corridor doors per the requirements of:

2012 NFPA 101, 19.3.6.3.5
42 CFR 483.90 (a) (1) (ii)

Findings include:

On 05/29/2018, during a tour of the facility from 9:15 am to 5:00 pm, the surveyor observed corridor doors that failed to positive latch in the frame at the following locations:

1. 6th floor room 610
2. 5th floor North corridor next to Omnicell Room 513
3. 3rd floor Cat Lab #3 door
4. 3rd floor 3 West across from stairway #16 Staff Office Door

A member of the maintenance staff was present when this deficiency was identified.

.

.

Based on observation and interview, the facility failed to maintain a smoke barrier that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of:

2012 NFPA 101, 19.3.7.3, 8.5.1, and 8.5.6.2

Findings include:

A. On 05/30/2018, during a tour of the facility from 7:45 am to 5:15 pm, the surveyor observed the following above the ceiling:
1. 2nd floor - the one hour rated smoke barrier located in the MICU Break Room was observed with unprotected wood at the deck
2. 2nd floor - in the corridor one hour rated smoke barrier wall at the CVSU Waiting Room: the HVAC duct was not sealed at the top
3. 2nd floor - in the corridor at the above the smoke barrier doors at the CVSU Waiting Room the following unsealed penetrations were observed:
a. one conduit
b. a bundle of wires (yellow, grey, blue, and black)


39326


B. On 05/29/2018, during a tour of the facility from 9:15 am to 5:00 pm, the surveyor observed the following unsealed penetrations above the ceiling in the following smoke barriers:
1. A four inch around one copper line/pipe on 3rd floor East Exit at Cat Lab.
2. A two inch around conduit on 3rd floor West smoke doors at the Nurses' Station

A member of the maintenance staff was present when this deficiency was identified.
.

.

Based on observation and interview, the facility failed to maintain a smoke barrier that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of:

2012 NFPA 101, 19.3.7.3, 8.5.1, and 8.5.6.2

Findings include:

On 05/29/2018, during a tour of the facility from 9:15 am to 5:00 pm, the surveyor observed an approximately four inch unsealed penetration around conduit with several blue wires at the ceiling in the smoke barrier in ACC building next to Radiology.

A member of the maintenance staff was present when this deficiency was identified.

.

Based on observation and interview, the facility failed to maintain the electrical wiring and equipment per the requirements of:

2012 NFPA 101, 19.5.1.1, and 9.1.2
2011 NFPA 70, 400.7 (B), and 314.28(c)
S&C 14-46

Findings include:

A. On 05/30/2018, during a tour of the facility from 7:45 am to 5:15 pm, the surveyor observed computers plugged into a power strip, plugged into another power strip, plugged into another power strip at the 4th floor Neuro Nurses' Station.


36148

B. On 05/29/2018, during a tour of the facility from 9:15 am to 5:00 pm, the Women's Hospital's Electrical Room on the 6th floor near room 6028 was observed with an electrical junction box with its cover plate not in place.


39326

C. On 05/29/2018, during a tour of the facility from 9:15 am to 5:00 pm, the Main Building on the 6th floor was observed with electrical junction box cover plates missing/not in place in the following locations above the ceiling:
1. Therapy Manager's Office next to the Soiled Utility Room
2. East main elevators at the Nurses' Station

A member of the maintenance staff was present when this deficiency was identified.
.

.

Based on observation and interview, the facility failed to maintain the HVAC per the requirements of:

2012 NFPA 101, 19.5.2.1, and 9.2
2012 NFPA 90A, 5.4.8.2
2010 NFPA 105, 5.2.3.1

This deficiency could affect 2 smoke compartments.

Findings include:

On 5/30/2018, during a tour of the facility from 7:45 am to 5:15 pm, during the testing of the smoke dampers the surveyor observed the smoke damper located at the "Old Women's Unit" by LDR 14 did not close upon activation of the two nearest smoke detectors.

A member of the maintenance staff was present when this deficiency was identified.
.

.

Based on observation and interview, the facility failed to maintain the hydraulic elevator hoistways and pits per the requirements of:

2012 NFPA 101, 19.5.3, and 9.4
1996 ASME A 17.1, 1206.2a

Findings include:

On 05/31/2018, during a tour of the facility from 7:45 am to 5:00 pm, the following hydraulic elevator hoistways and pits were observed with excessive amounts of dirt and rubbish:
1. Main Hospital elevator shaft 2930
2. Main Hospital ADHEC/PSYCH
3. Main Hospital Service/Surgery
4. Estes Building/West Main 6 & 7

A member of the maintenance staff was present when this deficiency was identified.
.

.

Based on review of documentation and interview, the facility failed to conduct fire drills per the requirements of:

2012 NFPA 101, 19.7.1.4 - 19.7.1.7, and 4.7.2

Findings include:

On 05/30/2018, during a review of documentation from 7:45 am to 5:00 pm, the facility failed to conduct fire drills for the Baylor/weekend staff.

A member of the maintenance staff was present when this deficiency was identified.

.

.

Based on observation, review of documentation and interview, the facility failed to maintain the cubicle curtains per the requirements of:

2012 NFPA 101, 19.7.5.1, and 10.3.1

Findings include:

On 05/31/2018, during a tour of the facility from 7:45 am to 5:00 pm, the facility failed to provide documentation the disposable cubicle curtains in the PACU Ward meet the flame propagation performance criteria contained in NFPA 701.

A member of the maintenance staff was present when deficiency was identified.
.

.

Based on review of documentation and interview, the facility failed to test the diesel generators' fuel quality per the requirements of:

2012 NFPA 99, 6.4.4.1.1.3
2010 NFPA 110, 8.3.8

Findings include:

On 05/31/2018, during a tour of the facility from 7:45 am to 5:00 pm, the facility failed to provided documentation that the fuel in the five diesel tanks had been tested within the past 12 months.

A member of the maintenance staff was present when deficiency was identified.

.

.

Based on review of documentation and interview, the facility failed to provide documentation of testing the diesel generator per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.4.4.1.1.3, and 6.5.4.2
2010 NFPA 110, 1.3, 8.3.8, 8.4.1, 8.4.2, and 8.4.2.3

Findings include:

On 5/31/2017, during a tour of the facility from 8:45 a.m. to 10:15 a.m., based on review of documentation and interview the facility failed to:

1. Test the diesel generator once monthly for a minimum of 30 minutes under loading that maintains the minimum exhaust gas temperature OR under operating temperature conditions at not less than 30% of the nameplate kW rating OR provide an annual 1.5 hour supplemental load test at not less than 50% of the EPS nameplate kW rating for 30 continuous minutes and at not less 75% of the EPS nameplate kW rating for one continuous hour for a total test duration of not less than 1.5 continuous hours.

2. To have a fuel quality test performed at least annually using tests approved by ASTM standards.

A member of the maintenance staff was present when this deficiency was identified.

.

Based on observation and interview, the facility failed to maintain the oxygen storage per the requirements of:

2012 NFPA 99, 11.3.2.3 (2), 11.6.2.3 (11), and 11.6.5.3

Findings include:

A. On 05/30/2018, during a tour of the facility from 7:45 am to 5:15 pm, the surveyor observed oxygen cylinders being stored within 3'-0" of combustibles in a storage room protected by automatic sprinklers in the following locations:
1. 7th floor - New Supply Room (old Conference Room) across from the Nurses' Station
2. 4th floor - Clean Utility Room


36148


B. On 05/29/2018, during a tour of the facility from 9:15 am to 5:00 pm, the surveyor observed the following at the Women's Hospital:
1. Four unsecured oxygen cylinders in the Medical Air Room on the 2nd floor parking deck
2. The 1st floor Main OR Oxygen Storage Room was observed with oxygen cylinders not marked (full or empty) to avoid confusion and delay.

A member of the maintenance staff was present when this deficiency was identified.