HospitalInspections.org

Applicable to 2000 Scenic Drive location.

The surveyor observed, while accompanied by the Director of Engineering, Quality Coordinator, and Engineering Technician, during the hours of the survey from 8 am - 4 pm on 07/31/19 that there were the following issues:

1) Based on observations the facility failed to maintain egress doors in the mechanical room on the first floor. The egress doors require more effort than normal to be able to exit the building from the egress side. The releasing mechanism was not obvious under all lighting conditions (including the dark).

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Hospital - 919 E 32nd Street Location:

The inspector observed, while accompanied by the Emergency Management Manager and the Construction Project Manager, during the hours of the inspection from 9:00 am to 5:30 pm on 7/30/2019 that there were the following issues.

1. The wall above the double fire doors, located near the food services area, had a hole through the wall that must 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.


2. 2nd Floor Supply room, near room #247 and the 2nd Floor Male Locker: Items on the shelves and on the lockers were too close to the sprinkler heads per the following.

"The clearance between the deflector and the top of storage shall be 18 inches or greater." - NFPA 13, 2010: 8.5.6.1.


3. 5th Floor Electrical room located near room #523: There were holes in the gypsum board wall and ceiling that needed to be sealed per the following requirement.

"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.
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Hospital - 919 E 32nd Street Location:

The inspector observed, while accompanied by the Emergency Management Manager and the Construction Project Manager, during the hours of the inspection from 9:00 am to 5:30 pm on 7/30/2019 that there were the following issues. They were:
Not all documents were available for review for flame spread ratings.


Heart Hospital - 3801 N Lamar Location:

The inspector observed, while accompanied by the Director of Facilities Manager and the Regulatory Coordinator during the hours of the inspection from 9:00 am to 3:00 pm on 8/1/2019 that there were the following issues.

Not all documents were available for review for flame spread ratings.

Hospital - 919 E 32nd Street Location:

The inspector observed, while accompanied by the Emergency Management Manager and the Construction Project Manager, during the hours of the inspection from 9:00 am to 5:30 pm on 7/30/2019 that there were the following issues.

1. Kitchen: The Walk-In Freezers and Refrigerators did not have windows, nor did they have audible or visual fire alarm notification devices.

2. Elevator #27 Lobby double exit doors and the Red River dock exit: These exits must have fire alarm pull boxes.

A manual fire alarm box shall be provided in the natural exit access path near each required exit from an area, unless modified by another section of this Code. NFPA 101, 2003, 9.6.2.3.

Item ##: Please provide fire alarm pull stations to be located within 5 feet of each exit door.

"Initiation of the required fire alarm systems shall be by manual means in accordance with 9.6.2 and by means of any detection devices or detection systems required." - NFPA 101, 2003, 20.3.4.2. (see next)

A manual fire alarm box shall be provided in the natural exit access path near each required exit from an area, unless modified by another section of this Code. NFPA 101, 2003, 9.6.2.3.

"Manual fire alarm boxes shall be located within 1.5m (5 feet) of exit doorway opening at each exit on each floor." NFPA 72, 2004, 5.12.6

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Heart Hospital - 3801 N Lamar Location:

The inspector observed, while accompanied by the Director of Facilities Manager and the Regulatory Coordinator during the hours of the inspection from 9:00 am to 3:00 pm on 8/1/2019 that there were the following issues.

Kitchen: The Walk-In Freezers and Refrigerators did not have windows, nor did they have audible or visual fire alarm notification devices.

K500 - Relative Humidity and Temperature Logs

Findings at 919 E. 32nd Street location.

The surveyor observed, while accompanied by the Construction Manager, EOC Manager, Manager of Safety/Emergency Management, and Facilities Coordinator, during the hours of the survey from 9am - 5:30pm on 07/30/19 that there were the following issues:

1) Based on review of the records, facility failed to log the relative humidity and temperature for anesthetizing locations in a manner that avoided confusion. If using the 12-hour format, please indicate whether time recorded is ante meridiem or post meridiem.

Findings at 919 E. 32nd Street location.

The surveyor observed, while accompanied by the Construction Manager, EOC Manager, Manager of Safety/Emergency Management, and Facilities Coordinator, during the hours of the survey from 9am - 5:30pm on 07/30/19 that there were the following issues:

1) Based on observation, the facility failed to maintain HVAC equipment. The magnehelic for air handling unit ("AHUG06-CCV") in the basement mechanical room appeared non-operational.

Hospital - 919 E 32nd Street Location:

The inspector observed, while accompanied by the Emergency Management Manager and the Construction Project Manager during the hours of the inspection from 9:00 am to 5:30 pm on 7/30/2019 that there were the following issues.

Not all documents were available for review for flame spread ratings.

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Rehabilitation Hospital - 1005 E 32nd Street Location:

The inspector observed, while accompanied by the Emergency Management Manager and the Construction Project Manager, during the hours of the inspection from 9:00 am to 12:30 pm on 7/31/2019 that there were the following issues.

Not all documents were available for review for flame spread ratings.


Heart Hospital - 3801 N Lamar Location:

The inspector observed, while accompanied by the Director of Facilities Manager and the Regulatory Coordinator, during the hours of the inspection from 9:00 am to 3:00 pm on 8/1/2019 that there were the following issues.

Not all documents were available for review for flame spread ratings.

Hospital - 919 E 32nd Street Location:

The inspector observed, while accompanied by the Emergency Management Manager and the Construction Project Manager, during the hours of the inspection from 9:00 am to 5:30 pm on 7/30/2019 that there were the following issues.

Not all documents were available for review for flame spread ratings.

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Rehabilitation Hospital - 1005 E 32nd Street Location:

The inspector observed, while accompanied by the Emergency Management Manager and the Construction Project Manager during the hours of the inspection from 9:00 am to 12:30 pm on 7/31/2019 that there were the following issues.

Not all documents were available for review for flame spread ratings.

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Heart Hospital - 3801 N Lamar Location:

The inspector observed, while accompanied by the Director of Facilities Manager and the Regulatory Coordinator during the hours of the inspection from 9:00 am to 3:00 pm on 8/1/2019 that there were the following issues.

Not all documents were available for review for flame spread ratings.

K900 - Health Care Facilities Code - ASHRAE 170 (2008)

Findings at 2000 Scenic Drive location.

The surveyor observed, while accompanied by the Director of Engineering, Quality Coordinator, and Engineering Technician, during the hours of the survey from 8am-4pm on 07/31/19 that there were the following issues:

1) Based on observation on the 2nd floor IT Closet near central elevator lobby, the facility failed to maintain ventilation requirements. There was a mechanical air vent at ceiling level that was fully obstructed by a piece of covering material.

2) Based on observation on the 2nd floor storage supply room near central elevator lobby, the facility failed to maintain ventilation requirements. There was no means of air changes in this room due to lack of supply and return vents.

3) Based on observation the facility utilized the endoscopy room for both bronchoscopy and endoscopy with provisions for switching between positive and negative airflow based on use. Please note per Addendum w to ASHRAE 170 (2008), "if the planned space is designated in the organization's operational plan to be utilized for both bronchoscopy and gastrointestinal endoscopy, the design parameters for "bronchoscopy, sputum collection, and pentamidine administration" shall be used."


Findings at 919 E. 32nd Street location.

The surveyor observed, while accompanied by the Construction Manager, EOC Manager, Manager of Safety/Emergency Management, and Facilities Coordinator, during the hours of the survey from 9am - 5:30pm on 07/30/19 that there were the following issues:

1) Based on observation the facility utilized the endoscopy room for both bronchoscopy and endoscopy with provisions for switching between positive and negative airflow based on use. Please note per Addendum w to ASHRAE 170 (2008), "if the planned space is designated in the organization's operational plan to be utilized for both bronchoscopy and gastrointestinal endoscopy, the design parameters for "bronchoscopy, sputum collection, and pentamidine administration" shall be used."

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Rehabilitation Hospital - 1005 E 32nd Street Location:

The inspector observed, while accompanied by the Emergency Management Manager and the Construction Project Manager, during the hours of the inspection from 9:00 am to 12:30 pm on 7/31/2019 that there were the following issues.

Risk Assessment for Medical Gas Systems and Electrical Systems were not available for review per the following.

Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99)

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Heart Hospital - 3801 N Lamar Location:

The inspector observed, while accompanied by the Director of Facilities Manager and the Regulatory Coordinator, during the hours of the inspection from 9:00 am to 3:00 pm on 8/1/2019 that there were the following issues.

Risk Assessment for Medical Gas Systems and Electrical Systems were not available for review per the following.

Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99)


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Hospital - 919 E 32nd Street Location:

The inspector observed, while accompanied by the Emergency Management Manager and the Construction Project Manager, during the hours of the inspection from 9:00 am to 5:30 pm on 7/30/2019 that there were the following issues.

In the "cave" mechanical room there was foil wrapped ducts in contact with copper medical gas lines. These dissimilar metals should be isolated from each other per the following requirement.

"Hangers and supports shall comply with and be installed in accordance with MSS SP-58, Pipe Hangers and Supports - Materials, Design, Manufacture, Selection, Application, and Installation." - NFPA 99, 2012, 5.1.10.11.4.2 NOTE: This does state that piping shall be isolated from incompatible materials.

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Heart Hospital - 3801 N Lamar Location:

The inspector observed, while accompanied by the Director of Facilities Manager and the Regulatory Coordinator, during the hours of the inspection from 9:00 am to 3:00 pm on 8/1/2019 that there were the following issues.

1. In the mechanical room there was foil wrapped ducts in contact with copper medical gas lines. These dissimilar metals should be isolated from each other per the following requirement.

"Hangers and supports shall comply with and be installed in accordance with MSS SP-58, Pipe Hangers and Supports - Materials, Design, Manufacture, Selection, Application, and Installation." - NFPA 99, 2012, 5.1.10.11.4.2 NOTE: This does state that piping shall be isolated from incompatible materials.

2. The 2nd floor medical gas room did not have an exhaust inlet near the floor per the following requirement.

"Mechanical exhaust to maintain a negative pressure in the space shall be provided continuously, unless an alternative design is approved by the authority having jurisdiction." - NFPA 99, 2012, 9.3.7.5.3.1

"Mechanical exhaust inlets shall be unobstructed and shall draw air from within 1 foot of the floor and adjacent to the cylinder or containers." - NFPA 99, 2012, 9.3.7.5.3.3


35321


Hospital - 919 E. 32nd Street location.

The surveyor observed, while accompanied by the Construction Manager, EOC Manager, Manager of Safety/Emergency Management and Facilities Coordinator, during the hours of the survey from 9am - 5:30pm on 07/30/19 that there were the following issues:

1) Based on observation, the facility failed to maintain mechanical ventilation for the central medical gas storage room. The mechanical exhaust inlet was heavily clogged with dust.

Hospital - 919 E 32nd Street Location:

The inspector observed, while accompanied by the Emergency Management Manager and the Construction Project Manager during the hours of the inspection from 9:00 am to 5:30 pm on 7/30/2019 that there were the following issues.

The electrical room located near food service and the electrical room near the maintenance cave had ladders and/or items stored in the room. This is not allowed per the following.

"Dedicated Equipment Space: All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage." - NFPA 70, 2012, 110.26(E)

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Heart Hospital - 3801 N Lamar Location:

The inspector observed, while accompanied by the Director of Facilities Manager and the Regulatory Coordinator, during the hours of the inspection from 9:00 am to 3:00 pm on 8/1/2019 that there were the following issues.

1. The 1st floor electrical room and the electrical room near the ORs had ladders stored in the rooms. This is not allowed per the following.

"Dedicated Equipment Space: All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage." - NFPA 70, 2012, 110.26(E)


2. 1st Floor Electrical Room: There was a panel box with a door that was missing latches to keep the door closed.

3. 1st Floor and 2nd Floor Electrical Rooms: The Life Safety panel box: The fire alarm breaker needs to have "Fire Alarm" written in red next to this breaker.

"The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit." - NFPA 72, 2010: 10.5.5.2.1

Hospital - 919 E 32nd Street Location:

The inspector observed, while accompanied by the Emergency Management Manager and the Construction Project Manager, during the hours of the inspection from 9:00 am to 5:30 pm on 7/30/2019 that there were the following issues.

Receptacle testing and maintenance logs for patient care area: "Records for tests and associated repairs or modifications containing date, room or area tested with results", were not available for review.

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Rehabilitation Hospital - 1005 E 32nd Street Location:

The inspector observed, while accompanied by the Emergency Management Manager and the Construction Project Manager during the hours of the inspection from 9:00 am to 12:30 pm on 7/31/2019 that there were the following issues.

Receptacle testing and maintenance logs for patient care area: "Records for tests and associated repairs or modifications containing date, room or area tested with results", were not available for review.


35321


Findings at 919 E. 32nd Street location.

The surveyor observed, while accompanied by the Construction Manager, EOC Manager, Manager of Safety/Emergency Management, and Facilities Coordinator, during the hours of the survey from 9 am - 5:30 pm on 07/30/19 that there were the following issues:

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 at 2000 Scenic Drive location.

The surveyor observed, while accompanied by the Director of Engineering, Quality Coordinator, and Engineering Technician, during the hours of the survey from 8am-4pm on 07/31/19 that there were the following issues:

Based on observations the facility failed to maintain the facility. Data cables and wiring were not securely fastened in place above the ceiling throughout most of facility.

NFPA 70; 2002: 800.52 (E) ...... Raceways shall be used for their intended purpose. Communication cables or wires shall not be strapped, taped, or attached by any means to the exterior of any conduit or raceway as a means of support.

NFPA 70; 2002: 800.52 (B) ...... The accessible portion of abandoned communications cables shall not be permitted to remain.