HospitalInspections.org

Based on observations during the tour of the facility on the morning of 09/10/2015, with the System Director of Engineering and Engineering Supervisor, the facility failed to maintain egress corridors. Waiting area was open to egress corridor with unattended coffee pots and no smoke detection present at McAllen Medical Center first floor mammography waiting.



Based on observations during the tour of the facility on the afternoon of 09/10/2015, with the System Director of Engineering and Engineering Supervisor, the facility failed to protect egress corridors. Dietary ware wash room was open onto the egress corridor. This is a negatively pressurized room however, if a fire was present in this room, smoke would spread into the egress corridor since its exhaust does not pull enough to remove that much smoke from entering the egress corridor. The existing roll down shutter was not connected to the fire alarm system. This occurred at McAllen Medical Center first floor dietary ' s ware wash.



Based on observations during the tour of the facility on the afternoon of 09/10/2015, with the System Director of Engineering and Engineering Supervisor, the facility failed to protect egress corridors. Fryer was open onto the egress corridor at McAllen Medical Center first floor dietary ' s servery.

Based on observations during the tour of the facility on the afternoon of 09/10/2015, with the System Director of Engineering and Engineering Supervisor, the facility failed to assure the doors in egress corridors had the required smoke control amenities. Double doors had a gap between the door ' s meeting edges, which could allow smoke from the room to enter the egress corridor. A smoke tight seal at the meeting edges of the doors when closed should be provided. This occurred at McAllen Medical Center ' s second floor endoscopy outpatient suite.



Based on observations during the tour of the facility on the 09/09/15 and 09/10/2015, with the System Director of Engineering and Engineering Supervisor, the facility failed to provide an acceptable means to protect the corridor. Suite ' s corridor door, where patients would be located, did not latch at its doorframe when the door was in a closed position. This occurred at McAllen Medical Center ' s 1) second floor mechanical room near ICU. This also occurred at Heart Hospital cath lab




Based on observations during the tour of the facility on the morning of 9/09/2015, with the Director of System Engineering, and the engineering supervisor, the facility failed to assure the integrity of the corridor at Edinberg Regional MC. The second floor Nurse ' s Lounge door did not have positive latching hardware. This was observed on more than one level, at each nursing staff lounge and physician lounge locations. For instance the 4th floor near the OR suite - Please provide positive door latching mechanisms.



Based on observations during the tour of the facility on the afternoon of 9/09/2015, with the Director of System Engineering, and the engineering supervisor at McAllen Heart Hospital; it was observed on Floor Two, at the Monitor Tech Room, SE side of the building - the double pair of doors leading into this room did not have an astragal forming a smoke tight condition to separate the room from the corridor. At Floor One, Provide positive latch at the Cauterization lab doors, labs - #1 & #3.

Based on observations during the survey walk of the facility on the morning of 9/10/2015, with the engineering supervisor at the McAllen Medical Center; It was observed at Level 7, Stair Well A, that fire proofing partially missing, or knocked of bottom of a beam, where the corridor side of the 2 hour wall intersects, and there is incomplete fire caulking along this edge.

Observation on 09/09/15 at 11:45 am, revealed the pair of smoke doors marked FD9 did not close completely when the fire alarm was activated as there was a gap between the doors which would allow smoke to enter or exit the two adjoining facilities (Edinburgh Regional/Edinburg Children ' s Hospital).




Based on observations during the survey walk of the facility on the morning of 9/09/2015, with the Director of System Engineering, and the engineering supervisor, at Edinberg Regional MC; It was observed that several Smoke Compartment walls did not close entirely during testing of the fire alarm system, either due to pressure differential or closer not operating correctly at the Admin. Suite; Outpatient Lab Services, and Pedi-ICU.



Based on observations during the survey walk of the facility on the morning of 9/09/2015, with the Director of System Engineering, and the engineering supervisor, at Edinberg Regional MC; It was observed that a pair of doors defining a suite of rooms did not near the level one main mechanical room did not have smoke control astragals installed to provide a smoke tight seal at the meeting edges of the doors when closed. See also near Radiology Suite, smoke compartment wall near radiology were missing astragals.

Based on observations during the survey walk of the facility on the morning of 9/10/2015, with the engineering supervisor at the McAllen Medical Center; It was observed at Level 7, Stair Well A, that fire proofing partially missing, or knocked of bottom of a beam, where the corridor side of the 2 hour wall intersects, and there is incomplete fire caulking along this edge.




Based on observations during the tour of the facility on the afternoon of 09/09/15, with the System Director of Engineering and Engineering Supervisor, the facility failed to maintain a rated barrier. Stairwell door did not latch into the doorframe when closed at McAllen Heart Hospital second floor stairwell.



Based on observations during the tour of the facility on the morning of 9/09/2015, with the Director of System Engineering, and the engineering supervisor, Fire door #3 did not close/latch properly, at Edinberg Regional MC

Based on observations during the tour of the facility on the 09/09/15 and 09/10/2015, with the System Director of Engineering and Engineering Supervisor, the facility failed to assure that the egress door was in compliance. The exit door from department ' s suite to the egress corridor was equipped with two latching arrangements from the egress side. Door shall be operable with not more than one releasing operation. This occurred at Edinberg Regional MC exiting dietary existing door had a thumb turn deadbolt latch and door lever latch in the means of egress. Provide panic bar, instead of two operations required to open the door.



At the Edinberg Regional MC, Based on observations during the tour of the facility on the morning of 9/10/2015, with the facility engineering supervisor, the security door at the dietary public serving area blocked the means to egress that space when closed. Relocate the existing exit sign at the security door to the opposite side of the room towards the adjacent conference room, through which an exit access corridor can be reached.

Based on observations during the tour of the facility on the 09/09/15 and 09/10/2015, with the System Director of Engineering and Engineering Supervisor, the facility failed to provide an exit sign marking the exit path. Two ways to egress are required upon entering the egress corridor. If one exit is becomes blocked, the other exit is marked and accessible In McAllen Medical Center, this occurred at the 1) second floor corridor endoscopy and 2) first floor corridor near vending machines and dietary department and 3) second floor surgery department, near operating room 5. In Heart Hospital, this occurred at cath lab recovery suite.



Based on observations during the tour of the facility on the 09/10/2015, with the System Director of Engineering and Engineering Supervisor, the facility failed to verify if the exit sign was sufficiently lit at McAllen Regional Medical Center ' s kitchen.
NFPA 99: 1999 3-5.2.2.1 .... Sufficient lighting in dining and recreation areas to provide illumination to exit ways of 5 footcandles minimum

Based on observations during the tour of the facility on the 09/09/15 and 09/10/2015, with the System Director of Engineering and Engineering Supervisor, the facility failed to assure correct cross labeling of the electrical (LS) panel that provides the power for the fire alarm system at various electrical panels at the Edinberg Regional MC - Breaker not identified with red - Fire Alarm, Life Safety Panel. Verify that the breakers shall be labeled at the panel that supplies power to the FACP. The label shall be placed immediately adjacent to the breaker and say " Fire Alarm Control Panel " and the breaker for all fire alarm circuits in the LS panels shall be colored red.

Based on observations during the tour of the facility on the morning of 9/09/2015, with the Director of System Engineering, and the engineering supervisor, at the Edinberg Regional MC; The bottom landing of an exit stair was not blocked with a rail or gate at the bottom to prevent use of that space as storage. A sprinkler below the bottom intermediate landing was not observed. Refer to 2000 NFPA 101 7.2.2.5.3.




Based on observations during the tour of the facility on the morning of 9/10/2015, with the facility engineering supervisor, at the McAllen Medical center; it was observed on the 9th Floor, Elevator Penthouse, that access to two communication provider (ATT & Verison) rooms not available. Confirm sprinkler coverage in these rooms.

Based on observations during the tour of the facility on the morning of 09/10/2015, with the System Director of Engineering and Engineering Supervisor, the facility failed to provide a manual pull box at McAllen Medical Center ' s emergency department ' s exit doors, near elevator lobby. This does not appear to be a required exit but verify with fire Marshall if removing the exit sign. NFPA 72: 5.12.6

Based on observations during the tour of the facility on the 0morning of 09/10/2015, with the System Director of Engineering and Engineering Supervisor, the facility failed to maintain sprinkler head. Sprinkler head had foreign material (paint) on it and must be replaced. This occurred at McAllen Medical Center ' s first floor loading dock.
NFPA 13: 6.2.6.4.4.... Sprinklers that have painted or coated shall be replaced in accordance with the requirements of 6.2.6.2.2 ....Where sprinklers have had paint applied by other than the sprinkler manufacturer, they shall be replaced with new listed sprinklers of the same characteristics, including orifice size, thermal response, and water distribution.



Based on observations during the tour of the facility on the afternoon of 09/10/2015, with the System Director of Engineering and Engineering Supervisor; the facility failed to maintain the fire alarm system. Sprinkler head was inside the duct insulation at McAllen Medical Center ' s second floor mechanical room, near operating department.



Based on observations during the tour of the facility on the morning of 9/10/2015, with the facility engineering supervisor, at the McAllen Medical center; a duct in a mechanical room on the 4/5 floor that was greater than 4 feet wide was observed not to have a sprinkler head below in accordance with NFPA 13



Based on observations during the survey walk of the facility on the afternoon of 9/09/2015, with the Director of System Engineering, and the engineering supervisor, at Edinberg Regional MC McAllen Heart Hospital; It was observed at Floor Two, Near the IT room, and at the first level, near the Bio-Med Room; a sprinkler head was lacking a proper escutcheon plate, please provide.

Based on observations during the tour of the facility on the afternoon of 09/10/2015, with the System Director of Engineering and Engineering Supervisor; the facility failed to maintain the filters at required by NFPA 90A. HVAC unit serving McAllen Medical Center ' s Surgery Suite draft gauge (manometer or magnahelic) across the final filter (90% efficiency) bed read 1.75.

Based on observations during the tour of the facility on the 09/09/15 and 09/10/2015, with the System Director of Engineering and Engineering Supervisor, the facility failed to provide proper distance between open flames and deep fry at McAllen Regional Medical Center ' s kitchen and servery and Edinburg Medical Center ' s kitchen. NFPA 96: 12.1.2.4 ..... All deep fat fryers shall be installed with at least a 16 inch space between the fryer and surface flames from adjacent cooking equipment.

Based on observations during the tour of the facility on the morning of 9/10/2015, with the facility engineering supervisor at Edinberg Regional MC, it was observed that some empty medical gas cylinders un-capped. It was also observed that some of the operating cylinders were exposed to the elements (not protected from sun) NFPA 99

Based on observations during the tour of the facility on the morning of 09/10/2015, with the System Director of Engineering and Engineering Supervisor, the facility failed to assure that the essential electrical system was in full compliance. Receptacle was powered by the life safety branch of the essential electrical system in panel 1LCC labeled OR MOB at McAllen Medical Center first floor ' s electrical room. Verify that any new circuit powered by the life safety branch complies with NFPA 99 ..... The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. communication systems, where used for issuing instruction during emergency conditions; 5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.



Based on observations during the tour of the facility on the morning of 09/10/2015, with the Engineering Supervisor at the McAllen Medical Center; it was observed that on the 4th, 5th 7th & 6th Floor, the essential power system panels marked life safety had circuits to powered elements that did not align with a type 1 system as defined by NFPA 99. (CONFIRM IF A COMMENT SINCE HOSPTIAL BUILT IN 1985)


Based on observations during the tour of the facility on the morning of 09/10/2015, with the Engineering Supervisor, the facility failed to maintain supporting cables in plenum space. NFPA 2002: 300.11 (A) ...... Cables and raceways shall not be supported by ceiling grids. NFPA 70: 300-11(a) ..... Bundle, secure, and support all low-voltage and signal wiring, cable, pneumatic tubing, fibre optics, etc. above the ceiling.
In McAllen Medical Center, this occurred at the 4th, 5th, 6th & 7th floor corridors where smoke compartment walls were inspected above the ceiling.


McAllen Heart Hospital - Floor Two, Elect Closet, Panel 2BLE - move the TV Monitor, temporary AHUs, off of the LS branch panel to the equipment panel. Refer to NFPA 99A 4.4.2.2.2.2 for 7 types life safety branch circuits that can be powered by these panels.



Based on observations during the tour of the facility on the morning of 09/10/2015, with the Engineering Supervisor, the facility failed to maintain Electrical junction boxes. Cover plate was missing over a circuit. NFPA 70, 2002: 314-28(C) and 314-24 .... All junction boxes of any nature are required to have properly secured cover plates with all wiring secured inside.



Based on observations during the survey walk of the facility on the afternoon of 9/09/2015, with the Director of System Engineering, and the engineering supervisor at the McAllen Heart Hospital; it was observed at the exterior emergency generator lacked a critical electrical outlet by identification. Please mark the electrical outlet on the LS branch inside of the generator with a red cover plate, and receptacle. NFPA 99 -