HospitalInspections.org

Based on the findings of the survey for compliance with the Life Safety Code conducted by staff of the Office of Health Care Quality on November 9, 2016, it was determined that the condition was Physical Environment was not met. The significant Life Safety Code survey findings included:

K0324 -Failure to comply with all requirements of NFPA 96 regarding fire protection for the cooking facilities

K0341 - Failure to provide a smoke detection system in the Rosenberg Building Outpatient Lobby area.

K0345 - Failure to maintain all fire alarm systems by not performing the required sensitivity test of the facility's fire alarm smoke detectors.

K0353- Failure to maintain all water based suppression systems as required by NFPA 25.

K0355 - Failure to fulfill all portable fire extinguisher installation requirements of NFPA 10 by not installing the required class "K" portable fire extinguisher for the Cafeteria.

K0362 -Failure to install a providing a wall with the proper fire resistant rating where the Pharmacy was expanded.

K0511- Failure to maintain all electrical utility equipment and installation requirements of NFPA 70 where there are combustible items stored on shelving units less than 36" from an 80 gallon electric water heater in the Kitchen storage area.

K0900 - Failure to store flammable or combustible liquids to be stored without required identification or markings.

K0918 -Failure to perform all emergency electrical systems inspection and testing requirements of NFPA 99 and 110.

K0923- Failure to provide required signage in medical gas storage locations in the building

Based on observations of respiratory rooms on two pediatric units, it was revealed that the hospital failed to post signs outside the rooms to indicate the presence of oxygen.

Tour of the hospital first floor revealed a respiratory room/closet which had six oxygen tanks but no signage outside the door to indicate the presence of oxygen tank storage.

Tour of the hospital second floor revealed a clean utility/respiratory room which had 29 oxygen tanks but no signage outside the door to indicate the presence of oxygen tank storage. On day two of the survey, signs were placed in both areas reflecting the presence oxygen tank storage in the rooms.

Based on the observations above, the hospital failed to ensure an acceptable level of safety on patient units.