HospitalInspections.org

The inspector observed while accompanied by the Director of Plant Operations and the Project Manager of Plant Operations during inspection conducted on 06-09-2016and 06-10-2016 that there was an existing open stairwell that does not meet curent space requirement. Provide a warning system to users by means of red stripping on floor.

The inspector observed while accompanied by the Director of Plant Operations and the Project Manager of Plant Operations during inspection conducted on 06-09-2016and 06-10-2016 that additional directional exit sign are needed at end of fifth floor corridors.

The inspector observed while accompanied by the Director of Plant Operations and the Project Manager of Plant Operations during inspection conducted on 06-09-2016and 06-10-2016 that AHU #2, #20, and #23 were missing sprinkler heads as required by NFPA13
Sprinklers shall be installed under fixed obstructions over 4 ft. wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors - NFPA 13, 2002: 8.5.5.3.1.

The inspector observed while accompanied by the Director of Plant Operations and the Project Manager of Plant Operations during inspection conducted on 06-09-2016and 06-10-2016 that there were low voltage cable resting on existing ceiling grid. Suspend low voltage cable from ceiling grid.
Physical environment. A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each hospital. The physical premises of the hospital and those areas of the hospital's physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and Subchapters H and I of this chapter Title 25, TAC, Ch. 133, HLR. DSHS; 2010: 133.162(d)(A).

The inspector observed while accompanied by the Director of Plant Operations and the Project Manager of Plant Operations during inspection conducted on 06-09-2016and 06-10-2016 that there were existing 1 hour fire walls and smoke walls that were not properly label.
All fire walls, fire barriers, fire partitions, smoke barriers, and smoke partitions shall be effectively and permanently identified with signs or stenciling per IBC 2012 section 703.7.


The inspector observed while accompanied by the Director of Plant Operations and the Project Manager of Plant Operations during inspection conducted on 06-09-2016and 06-10-2016 that there was a vent within 25' of existing RTU #3.
" Outside air intakes shall be located at least 25 feet from exhaust outlets of ventilating systems, combustion equipment stacks, medical-surgical vacuum systems, plumbing vents, or areas which may collect vehicular exhaust or other noxious fumes. (Prevailing winds and proximity to other structures may require more stringent requirements). Plumbing and vacuum vents that terminate five feet above the level of the top of the air intake may be located as close as 10 feet. " - H.L.R. 2007, 133.162(c)(3)(D)(i)(III).

The inspector observed while accompanied by the Director of Plant Operations and the Project Manager of Plant Operations during inspection conducted on 06-09-2016and 06-10-2016 that Life Safety Panels for each floor could not be found at each floor.
The life safety branch of the essential electrical system shall supply power for the following: 1) illumination of means of egress, 2) exit signs and exit direction signs, 3) fire alarm and medical gas alarm, 4) hospital communication systems where used for emergency conditions, 5) generator set location that includes task illumination, battery charger for battery-powered lighting, and selected receptacles, 6) elevator cab lighting, control, communication, and signal systems, 7) automatic doors used for building egress, and 8) auxiliary functions of the fire alarm combination systems complying with NFPA 72. No other functions than those listed above shall be connected to the life safety branch, NFPA 99, 2002, 4.4.2.2.2.2.
Provide proper location for Life Safety Panels.

The inspector observed while accompanied by the Director of Plant Operations and the Project Manager of Plant Operations during inspection conducted on 06-09-2016and 06-10-2016 that there was an existing open stairwell that does not meet curent space requirement. Provide a warning system to users by means of red stripping on floor.

The inspector observed while accompanied by the Director of Plant Operations and the Project Manager of Plant Operations during inspection conducted on 06-09-2016and 06-10-2016 that additional directional exit sign are needed at end of fifth floor corridors.

The inspector observed while accompanied by the Director of Plant Operations and the Project Manager of Plant Operations during inspection conducted on 06-09-2016and 06-10-2016 that AHU #2, #20, and #23 were missing sprinkler heads as required by NFPA13
Sprinklers shall be installed under fixed obstructions over 4 ft. wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors - NFPA 13, 2002: 8.5.5.3.1.

The inspector observed while accompanied by the Director of Plant Operations and the Project Manager of Plant Operations during inspection conducted on 06-09-2016and 06-10-2016 that there were low voltage cable resting on existing ceiling grid. Suspend low voltage cable from ceiling grid.
Physical environment. A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each hospital. The physical premises of the hospital and those areas of the hospital's physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and Subchapters H and I of this chapter Title 25, TAC, Ch. 133, HLR. DSHS; 2010: 133.162(d)(A).

The inspector observed while accompanied by the Director of Plant Operations and the Project Manager of Plant Operations during inspection conducted on 06-09-2016and 06-10-2016 that there were existing 1 hour fire walls and smoke walls that were not properly label.
All fire walls, fire barriers, fire partitions, smoke barriers, and smoke partitions shall be effectively and permanently identified with signs or stenciling per IBC 2012 section 703.7.


The inspector observed while accompanied by the Director of Plant Operations and the Project Manager of Plant Operations during inspection conducted on 06-09-2016and 06-10-2016 that there was a vent within 25' of existing RTU #3.
" Outside air intakes shall be located at least 25 feet from exhaust outlets of ventilating systems, combustion equipment stacks, medical-surgical vacuum systems, plumbing vents, or areas which may collect vehicular exhaust or other noxious fumes. (Prevailing winds and proximity to other structures may require more stringent requirements). Plumbing and vacuum vents that terminate five feet above the level of the top of the air intake may be located as close as 10 feet. " - H.L.R. 2007, 133.162(c)(3)(D)(i)(III).

The inspector observed while accompanied by the Director of Plant Operations and the Project Manager of Plant Operations during inspection conducted on 06-09-2016and 06-10-2016 that Life Safety Panels for each floor could not be found at each floor.
The life safety branch of the essential electrical system shall supply power for the following: 1) illumination of means of egress, 2) exit signs and exit direction signs, 3) fire alarm and medical gas alarm, 4) hospital communication systems where used for emergency conditions, 5) generator set location that includes task illumination, battery charger for battery-powered lighting, and selected receptacles, 6) elevator cab lighting, control, communication, and signal systems, 7) automatic doors used for building egress, and 8) auxiliary functions of the fire alarm combination systems complying with NFPA 72. No other functions than those listed above shall be connected to the life safety branch, NFPA 99, 2002, 4.4.2.2.2.2.
Provide proper location for Life Safety Panels.