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The inspector observed, while accompanied by The director of engineering and Maintenance, The safety manager, and The Administrative director of facility management, The facility consultant, the life safety administrative assistant, and the Director of infecting prevention during the hours of the inspection from 4:00 PM to 7:00 PM on 11/17/2015 and 9:30 AM to 5 PM on 11/18/2015, that there was the following issues:

A.)There was missing fire rated sealant/ caulking missing at one of the above ceiling of the fire rate and smoke barrier cross corridor door located at the Trinity tower ICU at the Baptist Beaumont Hospital.

B.) The smoke barrier cross corridor doors on hold open was not released upon the fire alarm system test at the Baptist Beaumont Behavior Hospital.

C.) The cross corridor door located at the smoke barrier compartment was not fully closed at the Baptist Beaumont Behavior Hospital.

D.) The cross corridor door located at the smoke barrier compartment was not fully closed located by the Room 246 at the Baptist Beaumont Hospital.

E.) The astragal at most the smoke barrier door need to be replace for smoke tight at the Baptist Beaumont Hospital and the Baptist Beaumont Behavior Hospital.

The inspector observed, while accompanied by The director of engineering and Maintenance, The safety manager, and The Administrative director of facility management, The facility consultant, the life safety administrative assistant, and the Director of infecting prevention during the hours of the inspection from 4:00 PM to 7:00 PM on 11/17/2015 and 9:30 AM to 5 PM on 11/18/2015, that there was the following issues:

A.) The door into the roof courtyard which have no exit access to the public way did not have a signage " Not an Exit " provided at the Baptist Beaumont Hospital second floor by the north tower.

The inspector observed, while accompanied by The director of engineering and Maintenance, The safety manager, and The Administrative director of facility management, The facility consultant, the life safety administrative assistant, and the Director of infecting prevention during the hours of the inspection from 4:00 PM to 7:00 PM on 11/17/2015 and 9:30 AM to 5 PM on 11/18/2015, that there was the following issues:


A.) An Audible and visible fire alarm notification device need to be installed on the 3rd level north-west corridor at the Baptist Beaumont Behavior Hospital.

The inspector observed, while accompanied by The director of engineering and Maintenance, The safety manager, and The Administrative director of facility management, The facility consultant, the life safety administrative assistant, and the Director of infecting prevention during the hours of the inspection from 4:00 PM to 7:00 PM on 11/17/2015 and 9:30 AM to 5 PM on 11/18/2015, that there was the following issues:

A) There were missing sprinkler escutcheon plates at the janitor closet on the 1st floor at the Baptist Beaumont Behavior Hospital.
B) The sprinkler head at the housekeeping room at the dining suite was located less than 4 " from the wall at the Baptist Beaumont Hospital.

Based on observation the facility failed to provide adequate medical gas system storage requirement.

The inspector observed, while accompanied by The director of engineering and Maintenance, The safety manager, and The Administrative director of facility management, The facility consultant, the life safety administrative assistant, and the Director of infecting prevention during the hours of the inspection from 4:00 PM to 7:00 PM on 11/17/2015 and 9:30 AM to 5 PM on 11/18/2015, that there was the following issues:

A.) There was no or permanent signage provided at the Medical Gas Storage Room exterior and interior door at the Baptist Beaumont Hospital and the Baptist Beaumont Behavior Hospital. Provide the following signage:

Re. NFPA 99, 2002: 5.1.3.1.5. The door shall have the following label:

Where nitrous oxide is used, the medical gas closet shall have a door labeled:

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

B.) The medical gas cylinders were not individually chained at the Baptist Beaumont Hospital.
C.) Provide protective cover for the medical gas cylinders at the exterior for inclement weather at the Baptist Beaumont Hospital.

The inspector observed, while accompanied by The director of engineering and Maintenance, The safety manager, and The Administrative director of facility management, The facility consultant, the life safety administrative assistant, and the Director of infecting prevention during the hours of the inspection from 4:00 PM to 7:00 PM on 11/17/2015 and 9:30 AM to 5 PM on 11/18/2015, that there was the following issues:

A.) The electrical connection between the panel/breaker and the FACP was not cross referenced correctly at the Baptist Beaumont Hospital and the Baptist Beaumont Behavior Hospital. Please provide label on the outside of the FACP panel as required.
B.) There labels provided for the essential transfer switches and the emergency electrical panels were not readily identifiable to identify life safety, critical and equipment branch at the Baptist Beaumont Hospital and the Baptist Beaumont Behavior Hospital.
C.) There was a missing receptacle powered from life safety branch at the essential automatic transfer switch location and the generator set location at the Baptist Beaumont Hospital.

The inspector observed, while accompanied by The director of engineering and Maintenance, The safety manager, and The Administrative director of facility management, The facility consultant, the life safety administrative assistant, and the Director of infecting prevention during the hours of the inspection from 4:00 PM to 7:00 PM on 11/17/2015 and 9:30 AM to 5 PM on 11/18/2015, that there was the following issues:

A.)There was missing fire rated sealant/ caulking missing at one of the above ceiling of the fire rate and smoke barrier cross corridor door located at the Trinity tower ICU at the Baptist Beaumont Hospital.

B.) The smoke barrier cross corridor doors on hold open was not released upon the fire alarm system test at the Baptist Beaumont Behavior Hospital.

C.) The cross corridor door located at the smoke barrier compartment was not fully closed at the Baptist Beaumont Behavior Hospital.

D.) The cross corridor door located at the smoke barrier compartment was not fully closed located by the Room 246 at the Baptist Beaumont Hospital.

E.) The astragal at most the smoke barrier door need to be replace for smoke tight at the Baptist Beaumont Hospital and the Baptist Beaumont Behavior Hospital.

The inspector observed, while accompanied by The director of engineering and Maintenance, The safety manager, and The Administrative director of facility management, The facility consultant, the life safety administrative assistant, and the Director of infecting prevention during the hours of the inspection from 4:00 PM to 7:00 PM on 11/17/2015 and 9:30 AM to 5 PM on 11/18/2015, that there was the following issues:

A.) The door into the roof courtyard which have no exit access to the public way did not have a signage " Not an Exit " provided at the Baptist Beaumont Hospital second floor by the north tower.

The inspector observed, while accompanied by The director of engineering and Maintenance, The safety manager, and The Administrative director of facility management, The facility consultant, the life safety administrative assistant, and the Director of infecting prevention during the hours of the inspection from 4:00 PM to 7:00 PM on 11/17/2015 and 9:30 AM to 5 PM on 11/18/2015, that there was the following issues:


A.) An Audible and visible fire alarm notification device need to be installed on the 3rd level north-west corridor at the Baptist Beaumont Behavior Hospital.

The inspector observed, while accompanied by The director of engineering and Maintenance, The safety manager, and The Administrative director of facility management, The facility consultant, the life safety administrative assistant, and the Director of infecting prevention during the hours of the inspection from 4:00 PM to 7:00 PM on 11/17/2015 and 9:30 AM to 5 PM on 11/18/2015, that there was the following issues:

A) There were missing sprinkler escutcheon plates at the janitor closet on the 1st floor at the Baptist Beaumont Behavior Hospital.
B) The sprinkler head at the housekeeping room at the dining suite was located less than 4 " from the wall at the Baptist Beaumont Hospital.

Based on observation the facility failed to provide adequate medical gas system storage requirement.

The inspector observed, while accompanied by The director of engineering and Maintenance, The safety manager, and The Administrative director of facility management, The facility consultant, the life safety administrative assistant, and the Director of infecting prevention during the hours of the inspection from 4:00 PM to 7:00 PM on 11/17/2015 and 9:30 AM to 5 PM on 11/18/2015, that there was the following issues:

A.) There was no or permanent signage provided at the Medical Gas Storage Room exterior and interior door at the Baptist Beaumont Hospital and the Baptist Beaumont Behavior Hospital. Provide the following signage:

Re. NFPA 99, 2002: 5.1.3.1.5. The door shall have the following label:

Where nitrous oxide is used, the medical gas closet shall have a door labeled:

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

B.) The medical gas cylinders were not individually chained at the Baptist Beaumont Hospital.
C.) Provide protective cover for the medical gas cylinders at the exterior for inclement weather at the Baptist Beaumont Hospital.

The inspector observed, while accompanied by The director of engineering and Maintenance, The safety manager, and The Administrative director of facility management, The facility consultant, the life safety administrative assistant, and the Director of infecting prevention during the hours of the inspection from 4:00 PM to 7:00 PM on 11/17/2015 and 9:30 AM to 5 PM on 11/18/2015, that there was the following issues:

A.) The electrical connection between the panel/breaker and the FACP was not cross referenced correctly at the Baptist Beaumont Hospital and the Baptist Beaumont Behavior Hospital. Please provide label on the outside of the FACP panel as required.
B.) There labels provided for the essential transfer switches and the emergency electrical panels were not readily identifiable to identify life safety, critical and equipment branch at the Baptist Beaumont Hospital and the Baptist Beaumont Behavior Hospital.
C.) There was a missing receptacle powered from life safety branch at the essential automatic transfer switch location and the generator set location at the Baptist Beaumont Hospital.