HospitalInspections.org

Based on observation the facility failed to maintain the fire resistance rating of the smoke barriers.

The inspector observed while accompanied by the hospital's Director of Physical Plant, the Director of Clinical Equipment Services, and the Environmental and Safety Manager during the hours of the inspection from 8:00 am to 5:30 pm that there were a few penetrations in the smoke barriers. These were located in the following: 1) the smoke barrier on the 6th floor by rooms 648 and 647, 2) the smoke barrier on the 3rd floor by rooms A316 and A315, and 3) the smoke barrier on the 1st floor by A114.

Based on observation the facility failed to provide an acceptable separation between a hazardous area and the rest of the facility.

The inspector observed while accompanied by the hospital's Director of Physical Plant, the Director of Clinical Equipment Services, and the Environmental and Safety Manager during the hours of the inspection from 8:00 am to 5:30 pm that the lab storage (adjacent to D114) was not separated from the rest of the facility correctly. This room requires a closer on the door.

Based on observation the facility failed to provide correct cross labeling of the FACP and the electrical panel that provides the power for the FACP.

The inspector observed while accompanied by the hospital's Director of Physical Plant, the Director of Clinical Equipment Services, and the Environmental and Safety Manager during the hours of the inspection from 8:00 am to 5:30 pm that in general throughout the hospital the FACP panel and subpanels were not always labeled as to which electrical panel and breaker supplied the power for the FACP. Also 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 shall be colored red.

Based on observation the facility failed to keep storage of materials the correct distance below the sprinkler heads.

The inspector observed while accompanied by the hospital's Director of Physical Plant, the Director of Clinical Equipment Services, and the Environmental and Safety Manager during the hours of the inspection from 8:00 am to 5:30 pm that there were two locations where items were stored above the 18 inch plane that starts from the bottom of the sprinkler head and goes downward. Items may not be stored above this plane because this can interfere with the sprinkler coverage. This was found in: 1) the pharmacy storage, and 2) the lab storage (adjacent to D114).

Based on observation the facility failed to provide an acceptable enclosure for the medical gases.

The inspector observed while accompanied by the hospital's Director of Physical Plant, the Director of Clinical Equipment Services, and the Environmental and Safety Manager during the hours of the inspection from 8:00 am to 5:30 pm that there was not a 45 minute rated door at the medical gas closet.

Based on observation the facility failed to provide an acceptable clearance around the bulk oxygen tanks.

The inspector observed while accompanied by the hospital's Director of Physical Plant, the Director of Clinical Equipment Services, and the Environmental and Safety Manager during the hours of the inspection from 8:00 am to 5:30 pm that there was a pickup truck parked in a no parking zone immediately adjacent to the bulk oxygen tanks. Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20 ft. of outside storage locations - NFPA 99, 1999, 8-3.1.11.2(i).


Based on observation the facility failed to provide an acceptable smoke damper on the outside air intake for anesthetizing locations.

The inspector observed while accompanied by the hospital's Director of Physical Plant, the Director of Clinical Equipment Services, and the Environmental and Safety Manager during the hours of the inspection from 8:00 am to 5:30 pm that there was not a smoke damper at the outside air intake for the surgical air handler(s). Ventilating systems for anesthetizing locations shall be provided that automatically prevent the circulation of smoke entering the system intake, without interfering with the exhaust function of the system - NFPA 99, 1999, 5-4.1.3. This type of damper shall be either a UL 555S or an AMCA standard 511, Class I smoke tight damper.


Based on observation the facility failed to provide acceptable scheduling of disaster drills.

The inspector observed while accompanied by the hospital's Director of Physical Plant, the Director of Clinical Equipment Services, and the Environmental and Safety Manager during the hours of the inspection from 8:00 am to 5:30 pm that the last disaster drill was on 6/25/09 and is the facility is overdue a drill.

Based on observation the facility failed to provide an acceptable sign on the medical gas closet.

The inspector observed while accompanied by the hospital's Director of Physical Plant, the Director of Clinical Equipment Services, and the Environmental and Safety Manager during the hours of the inspection from 8:00 am to 5:30 pm that the signage on the medical gas closet required modification. The sign shall state: Caution, Oxidizing Gases Stored Within, No Smoking.

Based on observation the facility failed to provide an acceptable Type 1 essential electrical system.

The inspector observed while accompanied by the hospital's Director of Physical Plant, the Director of Clinical Equipment Services, and the Environmental and Safety Manager during the hours of the inspection from 8:00 am to 5:30 pm that there were multiple problems with the EES that must be changed. These include: 1) in the generator room the exit signage was on the Critical Branch where it should be on the Life Safety Branch, 2) as a general note, the EES panels were not labeled " Life Safety " , " Critical " , and " Equipment " with permanent engraved plastic labels, 3) Life Safety panel BAXLA in the basement had numerous functions that are not allowed on the life safety panel, these must be moved to another panel, 4) the Fire Alarm Control Panel was on a critical panel, 4AXCA, this must be moved to a Life Safety panel, 5) in the Medication Room, A673, a refrigerator was on normal and must be on the Critical Branch, 6) in the E.R. department the ice machine was on normal and should be on Critical, 7) in electrical room, A175.1, there was a Critical panel that had medical gases (breaker 32) that must be moved to a Life Safety panel and a Damper (breaker 34) that must be moved to an Equipment panel, 8) in the ICU there was a medication dispensing machine that was on normal and must be moved to the Critical branch, 9) in electrical room, A163.1, the Life Safety panel, LLSA1, had exhaust fans that must be moved to the Equipment branch and ICU lighting and plug loads that must be moved to the Critical branch, 10) in electrical room, A163.1, the Life Safety panel, LLSA1, did not have the breaker labeled for the FACP and it was not colored red, also the directory needed to be updated.

Based on observation the facility failed to provide acceptable electrical wiring and equipment in accordance with NFPA 70, the National Electrical Code.

The inspector observed while accompanied by the hospital's Director of Physical Plant, the Director of Clinical Equipment Services, and the Environmental and Safety Manager during the hours of the inspection from 8:00 am to 5:30 pm that there were several problems with wiring. These were: 1) on the 4th floor electrical room, A466, there was a cable that came out of LCRA4 that was not in conduit, 2) at smoke barrier at A114 there was a j-box in the plenum that requires a cover, and 3) in the E.R. department the power poles in the treatment rooms do not have the correct labels on the critical receptacles that reference the panel and breaker supplying power.

Based on observation the facility failed to maintain the fire resistance rating of the smoke barriers.

The inspector observed while accompanied by the hospital's Director of Physical Plant, the Director of Clinical Equipment Services, and the Environmental and Safety Manager during the hours of the inspection from 8:00 am to 5:30 pm that there were a few penetrations in the smoke barriers. These were located in the following: 1) the smoke barrier on the 6th floor by rooms 648 and 647, 2) the smoke barrier on the 3rd floor by rooms A316 and A315, and 3) the smoke barrier on the 1st floor by A114.

Based on observation the facility failed to provide an acceptable separation between a hazardous area and the rest of the facility.

The inspector observed while accompanied by the hospital's Director of Physical Plant, the Director of Clinical Equipment Services, and the Environmental and Safety Manager during the hours of the inspection from 8:00 am to 5:30 pm that the lab storage (adjacent to D114) was not separated from the rest of the facility correctly. This room requires a closer on the door.

Based on observation the facility failed to provide correct cross labeling of the FACP and the electrical panel that provides the power for the FACP.

The inspector observed while accompanied by the hospital's Director of Physical Plant, the Director of Clinical Equipment Services, and the Environmental and Safety Manager during the hours of the inspection from 8:00 am to 5:30 pm that in general throughout the hospital the FACP panel and subpanels were not always labeled as to which electrical panel and breaker supplied the power for the FACP. Also 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 shall be colored red.

Based on observation the facility failed to keep storage of materials the correct distance below the sprinkler heads.

The inspector observed while accompanied by the hospital's Director of Physical Plant, the Director of Clinical Equipment Services, and the Environmental and Safety Manager during the hours of the inspection from 8:00 am to 5:30 pm that there were two locations where items were stored above the 18 inch plane that starts from the bottom of the sprinkler head and goes downward. Items may not be stored above this plane because this can interfere with the sprinkler coverage. This was found in: 1) the pharmacy storage, and 2) the lab storage (adjacent to D114).

Based on observation the facility failed to provide an acceptable enclosure for the medical gases.

The inspector observed while accompanied by the hospital's Director of Physical Plant, the Director of Clinical Equipment Services, and the Environmental and Safety Manager during the hours of the inspection from 8:00 am to 5:30 pm that there was not a 45 minute rated door at the medical gas closet.

Based on observation the facility failed to provide an acceptable clearance around the bulk oxygen tanks.

The inspector observed while accompanied by the hospital's Director of Physical Plant, the Director of Clinical Equipment Services, and the Environmental and Safety Manager during the hours of the inspection from 8:00 am to 5:30 pm that there was a pickup truck parked in a no parking zone immediately adjacent to the bulk oxygen tanks. Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20 ft. of outside storage locations - NFPA 99, 1999, 8-3.1.11.2(i).


Based on observation the facility failed to provide an acceptable smoke damper on the outside air intake for anesthetizing locations.

The inspector observed while accompanied by the hospital's Director of Physical Plant, the Director of Clinical Equipment Services, and the Environmental and Safety Manager during the hours of the inspection from 8:00 am to 5:30 pm that there was not a smoke damper at the outside air intake for the surgical air handler(s). Ventilating systems for anesthetizing locations shall be provided that automatically prevent the circulation of smoke entering the system intake, without interfering with the exhaust function of the system - NFPA 99, 1999, 5-4.1.3. This type of damper shall be either a UL 555S or an AMCA standard 511, Class I smoke tight damper.


Based on observation the facility failed to provide acceptable scheduling of disaster drills.

The inspector observed while accompanied by the hospital's Director of Physical Plant, the Director of Clinical Equipment Services, and the Environmental and Safety Manager during the hours of the inspection from 8:00 am to 5:30 pm that the last disaster drill was on 6/25/09 and is the facility is overdue a drill.

Based on observation the facility failed to provide an acceptable sign on the medical gas closet.

The inspector observed while accompanied by the hospital's Director of Physical Plant, the Director of Clinical Equipment Services, and the Environmental and Safety Manager during the hours of the inspection from 8:00 am to 5:30 pm that the signage on the medical gas closet required modification. The sign shall state: Caution, Oxidizing Gases Stored Within, No Smoking.

Based on observation the facility failed to provide an acceptable Type 1 essential electrical system.

The inspector observed while accompanied by the hospital's Director of Physical Plant, the Director of Clinical Equipment Services, and the Environmental and Safety Manager during the hours of the inspection from 8:00 am to 5:30 pm that there were multiple problems with the EES that must be changed. These include: 1) in the generator room the exit signage was on the Critical Branch where it should be on the Life Safety Branch, 2) as a general note, the EES panels were not labeled " Life Safety " , " Critical " , and " Equipment " with permanent engraved plastic labels, 3) Life Safety panel BAXLA in the basement had numerous functions that are not allowed on the life safety panel, these must be moved to another panel, 4) the Fire Alarm Control Panel was on a critical panel, 4AXCA, this must be moved to a Life Safety panel, 5) in the Medication Room, A673, a refrigerator was on normal and must be on the Critical Branch, 6) in the E.R. department the ice machine was on normal and should be on Critical, 7) in electrical room, A175.1, there was a Critical panel that had medical gases (breaker 32) that must be moved to a Life Safety panel and a Damper (breaker 34) that must be moved to an Equipment panel, 8) in the ICU there was a medication dispensing machine that was on normal and must be moved to the Critical branch, 9) in electrical room, A163.1, the Life Safety panel, LLSA1, had exhaust fans that must be moved to the Equipment branch and ICU lighting and plug loads that must be moved to the Critical branch, 10) in electrical room, A163.1, the Life Safety panel, LLSA1, did not have the breaker labeled for the FACP and it was not colored red, also the directory needed to be updated.

Based on observation the facility failed to provide acceptable electrical wiring and equipment in accordance with NFPA 70, the National Electrical Code.

The inspector observed while accompanied by the hospital's Director of Physical Plant, the Director of Clinical Equipment Services, and the Environmental and Safety Manager during the hours of the inspection from 8:00 am to 5:30 pm that there were several problems with wiring. These were: 1) on the 4th floor electrical room, A466, there was a cable that came out of LCRA4 that was not in conduit, 2) at smoke barrier at A114 there was a j-box in the plenum that requires a cover, and 3) in the E.R. department the power poles in the treatment rooms do not have the correct labels on the critical receptacles that reference the panel and breaker supplying power.