HospitalInspections.org

The inspector observed, while accompanied by the CEO, COO, CMO, CFO, Senior Vice President and CNE, Vice President of Clinical Excellence and Regulatory Compliance, Vice President of Clinical Excellence and Regulatory Compliance 2, Vice President of Operation, Manager of Facility Safety, Director of on 10/16/2019 that there were the following issues:


A) There were missing signage "No Exit "on the door exit out to the roof garden at the 2nd level. This is not in accordance with NFPA 101, 2003, 7.10.8.3.1 and 7.10.8.3.2. - No Exit. Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows: NO EXIT. Such sign shall have the word NO in letters 2 in. high with a stroke width of 3/8 in. and the word EXIT in letters 1 in. high, with the word EXIT below the word NO .

The inspector observed, while accompanied by the CEO, COO, CMO, CFO, Senior Vice President and CNE, Vice President of Clinical Excellence and Regulatory Compliance, Vice President of Clinical Excellence and Regulatory Compliance 2, Vice President of Operation, Manager of Facility Safety, Director of on 10/16/2019 that there were the following issues:


A) Some double egress corridor doors were not released for free egress from the magnetic lock device upon activate the fire alarm system. Please verify all other mag lock of the entire facility are released for free egress upon the fire alarm activation.

The inspector observed, while accompanied by the CEO, COO, CMO, CFO, Senior Vice President and CNE, Vice President of Clinical Excellence and Regulatory Compliance, Vice President of Clinical Excellence and Regulatory Compliance 2, Vice President of Operation, Manager of Facility Safety, Director of on 10/16/2019 that there were the following issues:


A) Some double egress corridor doors were not released for free egress from the magnetic lock device upon activate the fire alarm system. Please verify all other mag lock of the entire facility are released for free egress upon the fire alarm activation.

The inspector observed, while accompanied by the CEO, COO, CMO, CFO, Senior Vice President and CNE, Vice President of Clinical Excellence and Regulatory Compliance, Vice President of Clinical Excellence and Regulatory Compliance 2, Vice President of Operation, Manager of Facility Safety, Director of on 10/16/2019 that there were the following issues:

A) Some double egress corridor doors were not released from the magnetic hold open device upon activate the fire alarm system. Please verify all other mag hold of the entire facility are released for free egress upon the fire alarm activation.

The inspector observed, while accompanied by the CEO, COO, CMO, CFO, Senior Vice President and CNE, Vice President of Clinical Excellence and Regulatory Compliance, Vice President of Clinical Excellence and Regulatory Compliance 2, Vice President of Operation, Manager of Facility Safety, Director of on 10/16/2019 that there were the following issues:

A) Some of the smoke barrier partition or fire partition were not smoke or fire caulked.

The inspector observed, while accompanied by the CEO, COO, CMO, CFO, Senior Vice President and CNE, Vice President of Clinical Excellence and Regulatory Compliance, Vice President of Clinical Excellence and Regulatory Compliance 2, Vice President of Operation, Manager of Facility Safety, Director of on 10/16/2019 that there were the following issues:

A) Some of the fire dampers or smoke dampers access panels were not labeled.


B) There was not a fire/smoke damper provided at the 2 hours fire separation at one end of the connecting bridge located at the heart& spine hospital.

The inspector observed, while accompanied by the CEO, COO, CMO, CFO, Senior Vice President and CNE, Vice President of Clinical Excellence and Regulatory Compliance, Vice President of Clinical Excellence and Regulatory Compliance 2, Vice President of Operation, Manager of Facility Safety, Director of on 10/16/2019 that there were the following issues:

A) The smoke detector was not existed in the storage alcove which open into the egress corridor.


B) Some of the fire dampers or smoke dampers access panels were not labeled.

The inspector observed, while accompanied by the CEO, COO, CMO, CFO, Senior Vice President and CNE, Vice President of Clinical Excellence and Regulatory Compliance, Vice President of Clinical Excellence and Regulatory Compliance 2, Vice President of Operation, Manager of Facility Safety, Director of on 10/16/2019 that there were the following issues:

A) Some of the fire dampers or smoke dampers access panels were not labeled.

The inspector observed, while accompanied by the CEO, COO, CMO, CFO, Senior Vice President and CNE, Vice President of Clinical Excellence and Regulatory Compliance, Vice President of Clinical Excellence and Regulatory Compliance 2, Vice President of Operation, Manager of Facility Safety, Director of on 10/16/2019 that there were the following issues:

A) Some of the fire dampers or smoke dampers access panels were not labeled.


B) There was not a fire/smoke damper provided at the 2 hours fire separation at one end of the connecting bridge located at the heart& spine hospital.

The inspector observed, while accompanied by the CEO, COO, CMO, CFO, Senior Vice President and CNE, Vice President of Clinical Excellence and Regulatory Compliance, Vice President of Clinical Excellence and Regulatory Compliance 2, Vice President of Operation, Manager of Facility Safety, Director of on 10/16/2019 that there were the following issues:

A) If there is temperature and humidity variation will be adopted, please provide a letter indication that the hospital governing boy will adopt the CMS waiver Ref: S&C: 13-25-LSC & ASC.

The inspector observed, while accompanied by the CEO, COO, CMO, CFO, Senior Vice President and CNE, Vice President of Clinical Excellence and Regulatory Compliance, Vice President of Clinical Excellence and Regulatory Compliance 2, Vice President of Operation, Manager of Facility Safety, Director of on 10/16/2019 that there were the following issues:

A) Please provide risk assessment in accordance with NFPA 99, 2012.

The inspector observed, while accompanied by the CEO, COO, CMO, CFO, Senior Vice President and CNE, Vice President of Clinical Excellence and Regulatory Compliance, Vice President of Clinical Excellence and Regulatory Compliance 2, Vice President of Operation, Manager of Facility Safety, Director of on 10/16/2019 that there were the following issues:

A) Please provide risk assessment in accordance with NFPA 99, 2012.

The inspector observed, while accompanied by the CEO, COO, CMO, CFO, Senior Vice President and CNE, Vice President of Clinical Excellence and Regulatory Compliance, Vice President of Clinical Excellence and Regulatory Compliance 2, Vice President of Operation, Manager of Facility Safety, Director of on 10/16/2019 that there were the following issues:


(A) There was a missing receptacle powered from life safety branch and a battery back-up light fixture at some of the automatic transfer switch location.


(B) The label for FACP indicated as MSI -14 and there was no corresponded panel schedule existed. Please verify the FACP is powered from the life safety branch or correct the panel schedule on the life safety branch.


(C) Some of the electrical directory was not updated in accordance to the new or modified receptacles.


(D) Some emergency panels were not distinctively marked so that they are readily identifiable as a component of the essential electrical system.


(E) Please verify that there is a bonding wire provided between the normal and essential branch-circuits panelboards. Please reference NFPA 70, 2002: 517-14. - Panelboard bonding requires the equipment grounding terminal buses of the normal and essential branch-circuits panelboards serving the same individual patient vicinity be bonded together with an insulated continuous copper conductor not smaller than # 10 AWG.


(F) There was not an electrical panel and circuit number labeling on the face of the FACP


(G) There were flexible utilized from emergency life safety electrical panel (DPCPLA). This wiring system shall be a nonflexible metal raceway.


(H) Some medication room light fixtures were not powered from the generator emergency panel and correctly was powered from the normal power.

The inspector observed, while accompanied by the CEO, COO, CMO, CFO, Senior Vice President and CNE, Vice President of Clinical Excellence and Regulatory Compliance, Vice President of Clinical Excellence and Regulatory Compliance 2, Vice President of Operation, Manager of Facility Safety, Director of on 10/16/2019 that there were the following issues:

(A) There was a missing receptacle powered from life safety branch and a battery back-up light fixture at some of the automatic transfer switch location.


(B) Please verify that there is a bonding wire provided between the normal and essential branch-circuits panelboards. Please reference NFPA 70, 2002: 517-14. - Panelboard bonding requires the equipment grounding terminal buses of the normal and essential branch-circuits panelboards serving the same individual patient vicinity be bonded together with an insulated continuous copper conductor not smaller than # 10 AWG.

The inspector observed, while accompanied by the CEO, COO, CMO, CFO, Senior Vice President and CNE, Vice President of Clinical Excellence and Regulatory Compliance, Vice President of Clinical Excellence and Regulatory Compliance 2, Vice President of Operation, Manager of Facility Safety, Director of on 10/16/2019 that there were the following issues:


A) Please provide which OR rooms are wet procedure location.

Electrical Systems Wet Procedure Locations: Operating rooms are considered wet procedure locations, unless otherwise determined by a risk assessment conducted by the facility governing body. Operating rooms defined as wet locations are protected by either isolated power or ground-fault circuit interrupters. A written record of the risk assessment is maintained and available for inspection. NFPA 99 - 6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2.

The inspector observed, while accompanied by the CEO, COO, CMO, CFO, Senior Vice President and CNE, Vice President of Clinical Excellence and Regulatory Compliance, Vice President of Clinical Excellence and Regulatory Compliance 2, Vice President of Operation, Manager of Facility Safety, Director of on 10/16/2019 that there were the following issues. They were the following issues:

A) Please provide which OR rooms are wet procedure location.

Electrical Systems Wet Procedure Locations: Operating rooms are considered wet procedure locations, unless otherwise determined by a risk assessment conducted by the facility governing body. Operating rooms defined as wet locations are protected by either isolated power or ground-fault circuit interrupters. A written record of the risk assessment is maintained and available for inspection. NFPA 99 - 6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2.

The inspector observed, while accompanied by the CEO, COO, CMO, CFO, Senior Vice President and CNE, Vice President of Clinical Excellence and Regulatory Compliance, Vice President of Clinical Excellence and Regulatory Compliance 2, Vice President of Operation, Manager of Facility Safety, Director of on 10/16/2019 that there were the following issues:

A) There was no isolator provided between med gas copper pipes and the galvanized steel support at medical city hospital central plant.


B) The electrical device (fire pull) were located below 5'0" A.F.F. at the medical gas room. Please relocate it above 5'-0" A.F.F.

The inspector observed, while accompanied by the CEO, COO, CMO, CFO, Senior Vice President and CNE, Vice President of Clinical Excellence and Regulatory Compliance, Vice President of Clinical Excellence and Regulatory Compliance 2, Vice President of Operation, Manager of Facility Safety, Director of on 10/16/2019 that there were the following issues:


A) There was no isolator provided between med gas copper pipes and the galvanized steel support at medical city hospital central plant and the heart and spine hospital FDC room.


B) Provide permanent signage provided for medical gas storage room door to comply with NFPA 99, 2002: 5.1.3.1.5. The door shall have the following label:

CAUTION
Medical Gases
NO Smoking or Open Flame
Where nitrous oxide is used, the medical gas closet shall have a door labeled: Re. NFPA 99, 2002: 5.1.3.1.5. The door shall have the following label:


CAUTION
Medical Gases
NO Smoking or Open Flame
Room may have Insufficient Oxygen
Open Door and Allow Room to Ventilate before Entering


C) There were no dedicated mechanical exhaust systems that draw air from within 1 foot of the floor and operate continuously inside the medical storage rooms at the heart and spine hospital. This does not comply with NFPA 99 as followed: Re. NFPA 99, 2002: 5.1.3.3.3.1(E). Where the total volume of medical gases connected and in storage is less than 3000 cu.ft. at STP, natural ventilation shall be permitted - NFPA 99, 2002: 5.1.3.3.1(D). Where natural ventilation is permitted, it shall consist of two louvered openings, each having a minimum free area of 72 in. sq., with one located within 1 ft. of the floor and one located within 1 ft. of the ceiling . Re. NFPA 99, 2002: 5.1.3.3.3.1(B). - Where the total volume of medical gases connected and in storage is greater than 3,000 cu.ft. at STP, indoor supply locations shall be provided with dedicated mechanical ventilation systems that draw air from within 1 foot of the floor and operate continuously Re. NFPA 99, 2002: 5.1.3.3.3.1(F).- Louvered natural ventilation opening shall not be located in an exit corridor Re. NFPA 99, 2002: 5.1.3.3.3.1(G).- Mechanical natural ventilation shall be provided if the requirements of 5.1.3.3.3.1 cannot be met.

The inspector observed, while accompanied by the CEO, COO, CMO, CFO, Senior Vice President and CNE, Vice President of Clinical Excellence and Regulatory Compliance, Vice President of Clinical Excellence and Regulatory Compliance 2, Vice President of Operation, Manager of Facility Safety, Director of on 10/16/2019 that there were the following issues:


A) The policy and logs of the feature of fire protection - fire loss prevention in operating rooms was not available. Please provide updated policy for the fire loss prevention in operating room in accordance with NFPA 99, 2012, 15.13

The inspector observed, while accompanied by the CEO, COO, CMO, CFO, Senior Vice President and CNE, Vice President of Clinical Excellence and Regulatory Compliance, Vice President of Clinical Excellence and Regulatory Compliance 2, Vice President of Operation, Manager of Facility Safety, Director of on 10/16/2019 that there were the following issues:

A) The policy and logs of the feature of fire protection - fire loss prevention in operating rooms was not available. Please provide updated policy for the fire loss prevention in operating room in accordance with NFPA 99, 2012, 15.13