HospitalInspections.org

K200 Inspection of Doors in Means of Egress
Findings:
The inspector observed, while accompanied by the Facilities Manager, during the hours of the inspection from 10:30 AM to 5:45 PM on 10/09/19, that there were the following issues:
1) Based on staff interview, the facility failed to performance door maintenance. There was visible surface damage on the door to the soiled utility room located near acute care 3 nurse station.

K500 Building Services - Other
Findings:
The inspector observed, while accompanied by the Facilities Manager, during the hours of the inspection from 10:30 AM to 5:45 PM on 10/09/19, that there were the following issues:
1) Based on observation, the facility failed to document the appropriate temperature range for the operating room(s). Please note ASHRAE 170 (2008) is the most current edition adopted by HHSC.

K914 - Electrical Systems - Maintenance and Testing
Findings:
The inspector observed, while accompanied by the Facilities Manager, during the hours of the inspection from 10:30 AM to 5:45 PM on 10/09/19, that there were the following issues:
1) Based on observation, the facility failed to perform receptacle maintenance and testing for the years 2019, 2018, and 2017. NFPA 99-2012, section 6.3.3.2 lists the minimum requirements for receptacle testing regardless of hospital-grade or not. Describe the facility justification of testing frequency (e.g. appropriate testing intervals) based on documented performance data. For example, experiential data shows that retention force of the grounding blade of each electrical receptacle decreases over time due to repeated usage. Thus, the failure rate has a direct correlation to time and usage. What data does the facility collect or will implement that could provide the kind of indication of pending failures or reveal non-conformance receptacles such that it could take pre-emptive action before the onset of failure?