HospitalInspections.org

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Based on observation the facility failed to indicate on the face of the Fire Alarm Control Panel (FACP) the panel name and circuit number that provides power to the FACP and the mark the circuit breaker that provides power to the Fire Alarm system in red within the panel, as required by:

NFPA 72(1999)1-5.2.5.2.

The Facility Director stated on 02/02/17 at 1:45pm that the facility would make required revisions.
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Based on observation the facility failed to provide a fully exhaust system throughout the facility, as required by:

Department of State Health Services, Facility Licensing Group, Title 25, Texas Administrative Code, Chapter 133, Hospital Licensing State Regulations
§133.162. New Construction Requirements.
(d)(3)(D) Heating, ventilating and air conditioning (HVAC) systems. All HVAC systems shall comply with and shall be installed in accordance with the requirements of National Fire Protection Association 90A, Standard for the Installation of Air Conditioning and Ventilating Systems, 2002 edition, (NFPA 90A), NFPA 99, Chapter 6, the requirements contained in this subparagraph, and the specific requirements for a particular unit in accordance with §133.163 of this title.

(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.

(VII) Areas requiring fully ducted systems. Fully ducted supply, return and exhaust air for HVAC systems shall be provided for all critical care areas, sensitive care areas, all patient care areas, all areas requiring a sterile regimen, storage rooms, food preparation areas, and where required for fire safety purposes. Combination systems, utilizing both ducts and plenums for movement of air in these areas shall not be permitted.

(I) If the toilet is for patient use, an additional hand washing fixture shall be provided in each room at the entrance of the room. If the modular toilet/hand washing unit is for patient use, provision shall be made for patient privacy and odor control. The toilet room exhaust shall be in accordance with Table 3 of §133.169(c) of this title.

(C) The isolation room exhaust shall be a dedicated system which exhausts all air continuously to the exterior in accordance with Table 3 of §133.169(c) of this title. Multiple isolation rooms may be interconnected to the same exhaust system.

(viii) The isolation exhaust system shall be connected to the emergency essential electrical system.

The Facility Director stated on 02/02/17 at 2:40pm that the facility would make required revisions.
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Based on record review during the survey of the facility on the afternoon of 02/02/17 with the Facility Director, the facility failed to provide documentation that fire drills were conducted quarterly, during each shift, as required by NFPA 101, 19.7.1.4 through 19.7.1.721.3.4.1 and:

Department of State Health Services Facility Licensing Group, Title 25, Texas Administrative Code, Chapter 133, Hospital Licensing State Regulations:
§133.141. Fire Prevention and Protection.
(g) Fire drills. The hospital shall conduct at least 12 fire drills each year, one fire drill per shift per quarter, which shall include communication of alarms, simulation of evacuation of patients and other occupants, and use of fire-fighting equipment.

Record review of the facility provided documentation titled, "2016 Fire Drill Log" on the afternoon of 02/02/17 revealed there was no record for a fire drill conducted during the Second Quarter, Evening Shift.
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Based on observation the facility failed to provide a fully functioning nurse call system, as required by:

NFPA 99, 2002: 4.4.2.2.2.3 ..... The critical branch ... (5) nurse call systems.

Department of State Health Services, Facility Licensing Group, Title 25, Texas Administrative Code, Chapter 133, Hospital Licensing State Regulations
§133.162. New Construction Requirements.
(d)(5)(L) Nurses calling systems. Three different types of nurses calling systems are required to be installed in a hospital: a nurses regular calling system; a nurses emergency calling system; and a staff emergency assistance calling system. The hospital shall comply with the requirements of this subparagraph in addition to any specific requirements for nurses calling systems for the particular unit of the hospital in accordance with §133.163 and Table 7 of §133.169(g) of this title. Where required in this subparagraph, a distinct visible signal is provided when a colored dome light lamp, or particular combination of colored lamps is used for only one type of call. Different flash rates do not meet this requirement.

(i) A nurses regular calling system is intended for routine communication between each patient and the nursing staff. Activation of the system at a patient's regular calling station will sound a repeating (every 20 seconds or less) distinct audible signal at the nurse station, indicate type and location of call on the system monitor, and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. The audible signal shall be canceled and two-way voice communication between the patient room and the nursing staff shall be established at the unit's nursing station when the call is answered by the nursing staff. The visible signal(s) in the corridor shall be canceled upon termination of the call. Calls shall activate visible signals in accordance with Table 7 of §133.169(g) of this title. An alarm shall activate at the nurses station when the call cable is unplugged.

(ii) A nurses emergency calling system shall be installed in all toilets used by patients to summon nursing staff in an emergency. Activation of the system shall sound a repeating (every 5 seconds or less) a distinct audible signal at the nurse station, indicate type and location of call on the system monitor, and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. The visible and audible signals shall be cancelable only at the patient calling station. Calls shall activate visible signals in accordance with Table 7 of §133.169(g) of this title. When conveniently located and accessible from both the bathing and toilet fixtures, one emergency call station may serve one bathroom. A nurses emergency call system shall be accessible to a collapsed patient lying on the floor. Inclusion of a pull cord extending to within six inches of the floor will satisfy this requirement.

(iii) A staff emergency assistance calling system (code blue) is intended to be used by staff to summon additional help in an emergency. In open suites, an emergency assistant call system device shall be located at the head of each bed and in each individual room. The emergency assistance calling device can be shared between two beds if conveniently located. Activation of the system will sound a distinct audible signal at the nursing unit's nurses station or at a staffed control station of a suite, department or unit, indicate type and location of call on the system monitor and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. Calls shall activate audible and visible signals in accordance with Table 7 of §133.169(g) of this title. A visible system shall clearly define the alarm location to a continuously staffed back up area (other than the nurse station or an administrative center) from which assistance can be summoned. Alternatively, back up may be provided via automatic annunciation from the staff emergency assistance calling system through wireless phones or pagers. The system shall have voice communication capability so that the type of emergency or help required may be specified between the point of alarm and the unit's nurse station.

Figure: 25 TAC §133.169(g), Table 7 ... ... The nurse regular call system shall annunciate at the following rooms: Nurse Station, Clean Work Room, Soiled Work Room, Medication Room, Charting Room, Clean Linen Storage, Nourishment Room, Equipment Storage. Note 3 ..... The system shall have voice communication capabilities between the point of alarm and the nurse station so that the type of emergency or help required may be specified.

The Facility Director stated on 02/02/17 at 2:25pm that the facility would make required revisions.
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Based on observation the facility failed to provide electrical receptacle cover plates supplied from the life safety and critical branches marked with a non-removable label or engraved indicating the panel and circuit number, as required by:

NFPA 99; 2002: 4.4.2.2.2.2 ... ...The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment: 1. Illumination of means of egress as required in NFPA 101, Life Safety Code; 2. Exit signs and exit direction signs required in NFPA 101, Life safety Code; 3. Alarm and alerting systems including the following: a. Fire Alarms, b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems;" 4. (Hospital or ASC) communication systems, where used for issuing instruction during emergency conditions; 5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location; 6. Elevator ... 7. Automatically opened doors used for building egress. No functions other than those listed above in items 1 through 7 shall be connected to the life safety branch.

NFPA 99: 2002; 4.4.2.2.4.2 ..... The electrical receptacles or the cover plates for the electrical receptacles supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable.

HLR 2007: §133.162(d)(5)(H)(vi) ..... All critical care area receptacles shall be identified. The face plate for the receptacle(s) shall have a nonremovable label or be engraved indicating the panel and circuit number.

The inspector observed, while accompanied by the Facility Director on 02/02/17 from 1:00pm to 3:30pm that the red receptacles were marked with removeable tape or unmarked.

The Facility Director stated on 02/02/17 at 2:55pm that the facility would make required revisions.
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