The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
| UNIVERSITY OF TEXAS M D ANDERSON CANCER CENTER,THE | 1515 HOLCOMBE BLVD HOUSTON, TX | Sept. 12, 2019 |
| VIOLATION: Protection - Other | Tag No: K0300 | |
| Based on observation the facility failed to provide a complete protected fire assembly on 10th floor smoke compartment wall for east wing. "Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device." - NFPA 101, 2012, 8.3.5.1. Vestibule Protection: A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas except where specific sections of this standard permit the omission of sprinklers. NFPA 13, 2010: 4.1. Based on observation the facility failed to provide adequate fire protection. The inspector observed, while accompanied by the Director, Operations and Management, Director, EHS Sustain and Emergency Management (High Voltage and Generators) and Manager Electrical Systems during the hours of the inspection from 9:00 am to 5:00 pm on 9/10/2019 through 9/12/2019 during the hours of the inspection from 9:00 am to 5:00 pm on 9/10/2019 through 9/12/2019 that all the stair case vestibule in Lutheran building were protected by automatic sprinklers Per NFPA 13, 2010, this area shall be protected by automatic sprinklers. Ducts Protection: Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide, such as ducts, decks, open grate flooring, cutting tables, and overhead doors. NFPA, 2010:8.6.5.3.3. Based on observation the facility failed to provide adequate fire protection. The inspector observed, while accompanied by the Director, Operations and Management, Director, EHS Sustain and Emergency Management (High Voltage and Generators) and Manager Electrical Systems during the hours of the inspection from 9:00 am to 5:00 pm on 9/10/2019 through 9/12/2019 during the hours of the inspection from 9:00 am to 5:00 pm on 9/10/2019 through 9/12/2019 that some areas of the air handling duct systems across all the mechanical rooms on 15th, 8th, 6th and 4th floors did not have sprinkler heads installed under the duct to adequately protect the duct systems. Per NFPA 13, 2010, this area shall have automatic sprinklers installed. |
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| VIOLATION: Building Services - Other | Tag No: K0500 | |
| Based on observation the facility failed to provide a complete sprinkler assembly in room G 23.3424 - escutcheon plate missing. Escutcheons shall be part of the listed sprinkler assembly. - 2002 NFPA 13, 6.2.7.2 |
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| VIOLATION: General Requirements - Other | Tag No: K0100 | |
| Based on observation the facility failed to provide occupant load posting on the 24th floor observation deck per NFPA 101- 12.7.9.3 | ||
| VIOLATION: Means of Egress Requirements - Other | Tag No: K0200 | |
| Based on observation the facility failed to provide a proper clearance at various double egress doors. Facility to check and verify all double egress doors for requirement. | ||
| VIOLATION: Doors with Self-Closing Devices | Tag No: K0223 | |
| Based on observation the facility failed to provide a properly latching door at G 23.3437 Based on observation the facility failed to provide a properly latching door at G 22.3740 Based on observation the facility failed to provide a properly latching door at electrical room on the 22nd floor corridor leading to east wing. Based on observation the facility failed to provide a properly latching door at G 11.3631 |
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| VIOLATION: Electrical Systems - Other | Tag No: K0911 | |
| Labeling of Transfer Switches and Panels: All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system." - NFPA 70, 2011, 700.10. They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable. Based on observation the facility failed to provide adequate essential electrical system. The inspector observed, while accompanied by the Director, Operations and Management, Director, EHS Sustain and Emergency Management (High Voltage and Generators) and Manager Electrical Systems during the hours of the inspection from 9:00 am to 5:00 pm on 9/10/2019 through 9/12/2019 during the hours of the inspection from 9:00 am to 5:00 pm on 9/10/2019 through 9/12/2019 that they were: 1. In the mechanical room PB.3102 electrical panels were not identified as Life safety, Critical and Equipment panels. Consequently, circuits were haphazardly connected to the panels leading to incorrect circuits being connected on incorrect branches or panels. 2. In mechanical room P2.3104 an Equipment panel was incorrectly labeled a Life safety panel (by the facility proprietary labelling system) resulting in Fire Alarm Circuits to be connected to the Equipment branch. 3. Across board, re-inspect all the facility Essential Electrical System (EES) panels to ensure that they are correctly labelled and only the correct circuits are populated in the panels. Panel directory: Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard, and located at each switch or circuit breaker in a switchboard. No circuit shall be described in a manner that depends on transient conditions of occupancy." - NFPA 70, 2011, 408.4 (A) Note: Labeling includes all disconnecting means, see 110.22. Based on observation the facility failed to provide adequate Essential Electrical System (EES). The inspector observed, while accompanied by the Director, Operations and Management, Director, EHS Sustain and Emergency Management (High Voltage and Generators) and Manager Electrical Systems during the hours of the inspection from 9:00 am to 5:00 pm on 9/10/2019 through 9/12/2019 during the hours of the inspection from 9:00 am to 5:00 pm on 9/10/2019 through 9/12/2019 that many EES panel directories were not difficult to read. Panel directories shall be legible. . |
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