HospitalInspections.org

Based on observations during the survey walk of the facility on the afternoon of 6/17/2013, with the Fire Marshall and Parkland ' s guides/scribes, the facility failed to maintain a rated barrier. On the basement level, separating Parkland Hospital from UT Southwest, this pair of doors did not latch into each other's door edges when trying to close at the two hour separation barrier.

Based on observations during the survey walk of the facility on the afternoon of 6/17/2013, with the Fire Marshall and Parkland ' s guides/scribes, the facility failed to assure the integrity of the corridor. On ground floor, the lab's pair of doors had a gap between the meeting edges, possibly allowing smoke to penetrate into the egress corridor.
This also occureed at the cath lab recovery suite pair of doors. However the cath doors were being fixed on 6/17/2013.

Based on observations during the survey walk of the facility between 3:30 and 4:00 pm on 6/17/13, with the Director of Engineering and Parkland ' s guides/scribes, the facility failed to main corridor door in accordance with the 2000 edition of the Life Safety Code, NFPA (National Fire Protection Association) 101. Findings included the following:

Surveyor observed that on the Ninth Level west wing a floor stand created an impediment to closing corridor door to waiting room.

Based on observations during the survey walk of the facility on the afternoon of 6/17/2013, with the Fire Marshall and Parkland ' s guides/scribes, the facility failed to assure the protection of a hazardous room. Many supply boxes and combustible materials/goods were stored in a room that was kept open to the egress corridor. On ground level, the Volunteer Services door did not have a closure.

Based on observations during the survey walk of the facility on the afternoon of 6/17/2013, with the Fire Marshall and Parkland ' s guides/scribes, the facility failed to maintain the stairwell. On basement level, near cath lab department and electrical closets, combustible materials were being stored under the bottom landing and last run of the stairs.
This observation was being corrected on 6/17/2013, after it was noted.

Based on observations during the survey walk of the facility on the afternoon of 6/17/2013 and the morning of 6/18/2013, with the Director of Planning, Design, and Construction and Parkland ' s guides/scribes, the facility failed to display the required exit signage at Doors No. 2DS50, 3EES32, 3ES10, and 3DS29 and at basement level smoke compartment doors, leading from cath suite, near scrub shop.

Based on observations during the survey walk of the facility between 2:00 and 3:00 pm on 6/17/13, with the Director of Engineering and Parkland ' s guides/scribes, the facility failed to maintain fire alarm system in accordance with NFPA 101. Findings included the following:

Surveyor observed that on the Tenth Level, a fire alarm pull station was not at the natural path of exit from the North corridor.

Based on observations during the survey walk of the facility, with the Director of Engineering and Parkland ' s guides/scribes, the facility failed to maintain fire alarm system in accordance with NFPA 72. Findings included the following:

Survey observed between 3:30 and 4:00 pm on 6/17/13 that a fire alarm circuit on electrical distribution panel LPE 9 LS was not marked completely. The circuit breaker at the electrical panel board shall be identified with a red marking and identified as "FIRE ALARM CIRCUIT CONTROL" [NFPA 72, 1-5.2.8.2]

Surveyor observed between 2:00 and 3:00 pm on 6/18/13 that during testing of the fire alarm system on the Ground Level and Tenth Level manual initiation did not result in audible or visible signals. Staff suspended testing at that point.

Based on observations during the survey walk of the facility on the afternoon of 6/17/2013, with the Fire Marshall and Parkland ' s guides/scribes, the facility failed to maintain sprinkler heads. On basement level at the stairwell near the two hour separation, a sprinkler head had foreign material (paint) on it and must be replaced. Dust was on several sprinkler heads in the dirty linen chutes on basement level, ground level and first floor.
The dirty smoke detectors were cleaned off both days, after they were noted.



Based on observations during the survey walk of the facility on the afternoon of 6/18/2013, with the Fire Marshall and Parkland ' s guides/scribes, the ambulatory surgery center (ASC) facility failed to provide a sprinklered facility. The entire facility was sprinklered except for the vestibule at the ground level entry doors, near its lobby.

Based on observations during the survey walk of the facility, with the Director of Engineering and Parkland ' s guides/scribes, the facility failed to maintain
ventilating system in accordance with NFPA 101. Findings included the following:

1. Survey observed between 3:00 and 3:30 pm on 6/17/13 that on the Eleventh Level, standing water was standing under air handler in mechanical space.

2. Surveyor observed between 9:00 and 10 am on 6/18/13 that public toilet on the Eighth Level near the North elevator bank smelled of stale air.

3. Surveyor observed between 10 and 11:00 that Soiled Room G6.702 did not have proper negative ventilation.

Based on observations during the survey walk of the facility on the afternoon of 6/17/2013, with the Fire Marshall and Parkland ' s guides/scribes, the facility failed to provide protection from cooking surfaces. The fryer is directly next to the cooktop/griddle. All deep fat fryers shall be installed with at least a 16 inch space between the fryer and the surface flames from adjacent cooking equipment.

Based on observations during the survey walk of the facility between 3:00 and 3:30 pm on 6/17/13, with the Director of Engineering and Parkland ' s guides/scribes, the facility failed to maintain medical gas storage in accordance with the 1999 edition of the Standard for Health Care Facilities, NFPA 99. Findings included the following:

Surveyor observed between 3:00 and 3:30 pm on 6/17/13 that on the Tenth Level in west wing, one of six oxygen day cylinders was not secured in nursing unit storage room in accordance with NFPA 99, 1999: 4-3.5.2.2. All medical gas cylinders, in use or empty, shall be fastened to racks or otherwise secured in place to prevent damage to the cylinders. Empty cylinders shall be segregated from full cylinders, when stored in the same enclosure, and shall be marked to avoid confusion or delay if a full cylinder is needed in a hurry.

Based on observations during the survey walk of the facility on the morning of 6/17/2013, with the Fire Marshall and Parkland ' s guides/scribes, the facility failed to maintain a light fixture which illuminates the generator at emergency generator set location. The light, which was on battery power, did not illuminate when tested. It was located on the basement level, in the mechanical room.
This observation was being fixed on 6/18/2013, after it was noted.

Directional air flow. Ventilation systems shall be designed and balanced to provide directional flow as shown in Table 3 of ?133.169(c) of this title (Title 25 Texas Administrative Code, Chapter 133 Hospital Licensing Rules, ?133.162(d)(3)(D)(i)(VI).
Based on observations during the survey walk of the facility on the afternoon of 6/17/2013 and the morning of 6/18/2013, with the Director of Planning, Design, and Construction and Parkland ' s guides/scribes, the facility failed to achieve the required directional air flow (all rooms listed requiring "in" air flow) at Soiled Utility Room 2DC62W, Linen Chute Room 2CC7, L&D Supply Warehouse Room 3EC53, Envrironmental Services Room 3AC9, Janitor's Closet at Triage (Door No. 3EC13), Soiled Utility Room 3GC26, Soiled Linen Room 3GC1, and Soiled Utility Room 4DC4.

Based on observations during the survey walk of the facility on the morning and afternoon of 6/18/2013, with the Fire Marshall and Parkland ' s guides/scribes, the facility failed to assure that the essential electrical system was in full compliance. The hospital's basement level electrical room at panel board BGLSA, the circuit #23 supplied with power from the life safety branch of the essential electrical. Describe what this circuit goes to and determine if it should be on life safety panel based on the below requirements. Also at the ASC, the life safety panel's directory identified a crash cart receptacle on life safety. This can not be powered from life safety panel.
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. (Hospital or ASC) 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 survey walk of the facility on the afternoon of 6/18/2013, with the Fire Marshall and Parkland ' s guides/scribes, the facility failed to properly label panelboards. On the ground level, outside the pathology department, in the electrical room, a panel board (HGCC) powered by the Type I EES, could not be determined with which branch it was associated. All boxes and enclosures (including transfer switches, transformers, distribution panels, and panelboards) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system. The above listed components shall be labeled with the words " LIFE SAFETY " , " CRITICAL " AND " EQUIPMENT " to be readily identifiable as part of the Essential Electrical System.

Based on observations during the survey walk of the facility between 2:00 and 3:00 pm on 6/18/13, with the Director of Engineering and Parkland ' s guides/scribes, the facility failed to maintain fire alarm system in accordance with NFPA 101. Findings included the following:

Surveyor observed that fire alarm system was out of service. The authority having jurisdiction, including the Department of State Health Services, Architecture Review Group shall be notified of the results of the Fire Watch and the reactivation of the fire alarm system.

Based on observations during the survey walk of the facility on the afternoon of 6/17/2013, with the Fire Marshall and Parkland ' s guides/scribes, the facility failed to maintain a rated barrier. On the basement level, separating Parkland Hospital from UT Southwest, this pair of doors did not latch into each other's door edges when trying to close at the two hour separation barrier.

Based on observations during the survey walk of the facility on the afternoon of 6/17/2013, with the Fire Marshall and Parkland ' s guides/scribes, the facility failed to assure the integrity of the corridor. On ground floor, the lab's pair of doors had a gap between the meeting edges, possibly allowing smoke to penetrate into the egress corridor.
This also occureed at the cath lab recovery suite pair of doors. However the cath doors were being fixed on 6/17/2013.

Based on observations during the survey walk of the facility between 3:30 and 4:00 pm on 6/17/13, with the Director of Engineering and Parkland ' s guides/scribes, the facility failed to main corridor door in accordance with the 2000 edition of the Life Safety Code, NFPA (National Fire Protection Association) 101. Findings included the following:

Surveyor observed that on the Ninth Level west wing a floor stand created an impediment to closing corridor door to waiting room.

Based on observations during the survey walk of the facility on the afternoon of 6/17/2013, with the Fire Marshall and Parkland ' s guides/scribes, the facility failed to assure the protection of a hazardous room. Many supply boxes and combustible materials/goods were stored in a room that was kept open to the egress corridor. On ground level, the Volunteer Services door did not have a closure.

Based on observations during the survey walk of the facility on the afternoon of 6/17/2013, with the Fire Marshall and Parkland ' s guides/scribes, the facility failed to maintain the stairwell. On basement level, near cath lab department and electrical closets, combustible materials were being stored under the bottom landing and last run of the stairs.
This observation was being corrected on 6/17/2013, after it was noted.

Based on observations during the survey walk of the facility on the afternoon of 6/17/2013 and the morning of 6/18/2013, with the Director of Planning, Design, and Construction and Parkland ' s guides/scribes, the facility failed to display the required exit signage at Doors No. 2DS50, 3EES32, 3ES10, and 3DS29 and at basement level smoke compartment doors, leading from cath suite, near scrub shop.

Based on observations during the survey walk of the facility between 2:00 and 3:00 pm on 6/17/13, with the Director of Engineering and Parkland ' s guides/scribes, the facility failed to maintain fire alarm system in accordance with NFPA 101. Findings included the following:

Surveyor observed that on the Tenth Level, a fire alarm pull station was not at the natural path of exit from the North corridor.

Based on observations during the survey walk of the facility, with the Director of Engineering and Parkland ' s guides/scribes, the facility failed to maintain fire alarm system in accordance with NFPA 72. Findings included the following:

Survey observed between 3:30 and 4:00 pm on 6/17/13 that a fire alarm circuit on electrical distribution panel LPE 9 LS was not marked completely. The circuit breaker at the electrical panel board shall be identified with a red marking and identified as "FIRE ALARM CIRCUIT CONTROL" [NFPA 72, 1-5.2.8.2]

Surveyor observed between 2:00 and 3:00 pm on 6/18/13 that during testing of the fire alarm system on the Ground Level and Tenth Level manual initiation did not result in audible or visible signals. Staff suspended testing at that point.

Based on observations during the survey walk of the facility on the afternoon of 6/17/2013, with the Fire Marshall and Parkland ' s guides/scribes, the facility failed to maintain sprinkler heads. On basement level at the stairwell near the two hour separation, a sprinkler head had foreign material (paint) on it and must be replaced. Dust was on several sprinkler heads in the dirty linen chutes on basement level, ground level and first floor.
The dirty smoke detectors were cleaned off both days, after they were noted.



Based on observations during the survey walk of the facility on the afternoon of 6/18/2013, with the Fire Marshall and Parkland ' s guides/scribes, the ambulatory surgery center (ASC) facility failed to provide a sprinklered facility. The entire facility was sprinklered except for the vestibule at the ground level entry doors, near its lobby.

Based on observations during the survey walk of the facility, with the Director of Engineering and Parkland ' s guides/scribes, the facility failed to maintain
ventilating system in accordance with NFPA 101. Findings included the following:

1. Survey observed between 3:00 and 3:30 pm on 6/17/13 that on the Eleventh Level, standing water was standing under air handler in mechanical space.

2. Surveyor observed between 9:00 and 10 am on 6/18/13 that public toilet on the Eighth Level near the North elevator bank smelled of stale air.

3. Surveyor observed between 10 and 11:00 that Soiled Room G6.702 did not have proper negative ventilation.

Based on observations during the survey walk of the facility on the afternoon of 6/17/2013, with the Fire Marshall and Parkland ' s guides/scribes, the facility failed to provide protection from cooking surfaces. The fryer is directly next to the cooktop/griddle. All deep fat fryers shall be installed with at least a 16 inch space between the fryer and the surface flames from adjacent cooking equipment.

Based on observations during the survey walk of the facility between 3:00 and 3:30 pm on 6/17/13, with the Director of Engineering and Parkland ' s guides/scribes, the facility failed to maintain medical gas storage in accordance with the 1999 edition of the Standard for Health Care Facilities, NFPA 99. Findings included the following:

Surveyor observed between 3:00 and 3:30 pm on 6/17/13 that on the Tenth Level in west wing, one of six oxygen day cylinders was not secured in nursing unit storage room in accordance with NFPA 99, 1999: 4-3.5.2.2. All medical gas cylinders, in use or empty, shall be fastened to racks or otherwise secured in place to prevent damage to the cylinders. Empty cylinders shall be segregated from full cylinders, when stored in the same enclosure, and shall be marked to avoid confusion or delay if a full cylinder is needed in a hurry.

Based on observations during the survey walk of the facility on the morning of 6/17/2013, with the Fire Marshall and Parkland ' s guides/scribes, the facility failed to maintain a light fixture which illuminates the generator at emergency generator set location. The light, which was on battery power, did not illuminate when tested. It was located on the basement level, in the mechanical room.
This observation was being fixed on 6/18/2013, after it was noted.

Directional air flow. Ventilation systems shall be designed and balanced to provide directional flow as shown in Table 3 of ?133.169(c) of this title (Title 25 Texas Administrative Code, Chapter 133 Hospital Licensing Rules, ?133.162(d)(3)(D)(i)(VI).
Based on observations during the survey walk of the facility on the afternoon of 6/17/2013 and the morning of 6/18/2013, with the Director of Planning, Design, and Construction and Parkland ' s guides/scribes, the facility failed to achieve the required directional air flow (all rooms listed requiring "in" air flow) at Soiled Utility Room 2DC62W, Linen Chute Room 2CC7, L&D Supply Warehouse Room 3EC53, Envrironmental Services Room 3AC9, Janitor's Closet at Triage (Door No. 3EC13), Soiled Utility Room 3GC26, Soiled Linen Room 3GC1, and Soiled Utility Room 4DC4.

Based on observations during the survey walk of the facility on the morning and afternoon of 6/18/2013, with the Fire Marshall and Parkland ' s guides/scribes, the facility failed to assure that the essential electrical system was in full compliance. The hospital's basement level electrical room at panel board BGLSA, the circuit #23 supplied with power from the life safety branch of the essential electrical. Describe what this circuit goes to and determine if it should be on life safety panel based on the below requirements. Also at the ASC, the life safety panel's directory identified a crash cart receptacle on life safety. This can not be powered from life safety panel.
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. (Hospital or ASC) 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 survey walk of the facility on the afternoon of 6/18/2013, with the Fire Marshall and Parkland ' s guides/scribes, the facility failed to properly label panelboards. On the ground level, outside the pathology department, in the electrical room, a panel board (HGCC) powered by the Type I EES, could not be determined with which branch it was associated. All boxes and enclosures (including transfer switches, transformers, distribution panels, and panelboards) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system. The above listed components shall be labeled with the words " LIFE SAFETY " , " CRITICAL " AND " EQUIPMENT " to be readily identifiable as part of the Essential Electrical System.

Based on observations during the survey walk of the facility between 2:00 and 3:00 pm on 6/18/13, with the Director of Engineering and Parkland ' s guides/scribes, the facility failed to maintain fire alarm system in accordance with NFPA 101. Findings included the following:

Surveyor observed that fire alarm system was out of service. The authority having jurisdiction, including the Department of State Health Services, Architecture Review Group shall be notified of the results of the Fire Watch and the reactivation of the fire alarm system.