HospitalInspections.org

Observation revealed not all required door closers were installed. Please verify the following Department of State Health Services, Title 25 Texas Administrative Code, Chapter 133, Hospital Licensing Rules and codes are achieved:

(III) Overhead clearance. Suspended tracks, rails, pipes, signs, lights, door closers, exit signs, and other fixtures that protrude into the path of normal traffic shall not be less than six feet eight inches above the finished floor.

NFPA 101, 2003: 18.3.2.1 ..... Any hazardous areas shall be protected in accordance with Section 8.7, and the areas described in Table 18.3.2.1 shall be protected as indicated. The doors shall be a minimum ¾ hour fire rated doors set in rated frames. With that classification, the door's hardware, including door closers device and latching hardware, must meet the requirement for storage rooms.

NFPA 72E, 9-5. All doors in smoke barrier partitions must be control by a smoke detector (device) that is tied to the fire alarm system. The devices shall not be further than five feet of the doors and not closer then one foot of the doors.

Base on observation, the facility failed to provide fully functioning exhausts at all required locations, which is required by Department of State Health Services, Title 25 Texas Administrative Code, Chapter 133, Hospital Licensing Rules:

(i) General ventilation requirements. All rooms and areas in the hospital listed in Table 3 of §133.169(c) of this title shall have provision for positive ventilation. Fans serving exhaust systems shall be located at the discharge end and shall be conveniently accessible for service. Exhaust systems may be combined, unless otherwise noted, for efficient use of recovery devices required for energy conservation. The ventilation rates shown in Table 3 of §133.169(c) of this title shall be used only as minimum requirements since they do not preclude the use of higher rates that may be appropriate. Supply air to the building and exhaust air from the building shall be regulated to provide a positive pressure within the building with respect to the exterior.

Observation revealed storage rooms that exceeded 100 square feet did not have properly rateds walls, ceilings, doors, door frames or door hardware. Please renovate all storage rooms greater than 100 square feet to achieve the following:

NFPA 101, 2003, 18.3.2.1 .....Any hazardous areas shall be protected in accordance with Section 8.7, and the areas described in Table 18.3.2.1 shall be protected as indicated .....Storage rooms larger than 100 square feet and storing combustible material require 1 hour separation.

NFPA 101, 2003, 8.7.1.3 .....Doors in barriers required to have a fire resistance rating shall have a ¾ hour fire protection rating and shall be self-closing or automatic closing in accordance with 7.2.1.8.

Based on observation, the facility failed to provide ground-fault circuit interrupters (GFCI) at electrical receptacles within three feet of a water source at non-patient areas, which does not meet the following Department of State Health Services, Title 25 Texas, Administrative Code, Chapter 133, Hospital Licensing Rules requirement:

(J) Ground fault circuit interrupters (GFCI). GFCI receptacles shall be provided for all general use receptacles located within three feet of a wash basin or sink. When GFCI receptacles are used, they shall be connected to not affect other devices connected to the circuit in the event of a trip. Receptacles connected to the critical branch that may be used for equipment that should not be interrupted do not have to be GFCI protected. Receptacles in wet locations, as defined by NFPA 70, §§517.20 and 517.21, shall be GFCI protected regardless of the branch of the electrical system serving the receptacle.

Observation revealed exposed light bulbs, unprotected from breakage. Please provide and instal proper lens or covers to prevent harm from broken glass and to achieve the following requirement of Department of State Health Services, Title 25 Texas Administrative Code
Chapter 133, Hospital Licensing Rules:

(II) A reading light shall be provided for each patient. Reading light control shall be readily accessible from each patient bed. Flexible light arms, if used, shall be mechanically controlled to prevent the bulb from coming in contact with bed linen. High heat- producing light sources such as incandescent and halogen shall be avoided to prevent burns to patients and/or bed linen. Light sources shall be covered by a diffuser or a lens.