HospitalInspections.org

Based on observation the facility failed to provide acceptable smoke barrier partitions in multiple locations within the hospital.

The inspector observed while accompanied by the Director of Maintenance and the Director of Engineering during the hours of the inspection from 1:00 pm to 4:30 pm that there were incomplete smoke barriers where the barrier did not go up to deck, holes in smoke barriers, and/or gypsum board on only one side of the studs in the following locations: 1) an incomplete barrier located in the area between patient room 109 and 111, 2) a small hole above the medical gas line in the barrier leading to the CCU, 3) large holes at the barrier adjacent to the elevator lobby, 4) unprotected studs in the barrier adjacent to the west, large patient waiting room, and 5) a hole above a HVAC duct in the CCU waiting room. This type of violation was also reported in the previous Life Safety Code Survey and is a serious source of concern should this condition persist.

Based on observation the facility failed to provide an acceptable closer on a smoke barrier door.

The inspector observed while accompanied by the Director of Maintenance and the Director of Engineering during the hours of the inspection from 1:00 pm to 4:30 pm that there was a door in a smoke barrier between the observation room and the equipment room that did not have a closer. When the closer is added, this door may only be held open with a automatic release device that complies with 7.2.1.8.2 of the 2000 LSC.

Based on observation the facility failed to provide an acceptable separation between hazardous areas and the rest of the hospital.

The inspector observed while accompanied by the Director of Maintenance and the Director of Engineering during the hours of the inspection from 1:00 pm to 4:30 pm that there were multiple locations where the hospital was not providing acceptable separations between hazardous areas and the rest of the hospital. All of the following rooms did not have closers: 1) RT storage, 2) sterile supply, 3) ICU storage, 4) medical records, 5) the pantry, and 6) the dry storage.

Based on observation the facility failed to keep storage of materials the correct distance below the sprinkler heads.

The inspector observed while accompanied by the Director of Maintenance and the Director of Engineering during the hours of the inspection from 1:00 pm to 4:30 pm that there was storage within the pharmacy that was above the 18 inch plane that starts from the bottom of the sprinkler head and goes downward. Items may not be stored above this plane because this can interfere with the sprinkler coverage.

Based on observation the facility failed to provide acceptable shower and cubicle curtains.

The inspector observed while accompanied by the Director of Maintenance and the Director of Engineering during the hours of the inspection from 1:00 pm to 4:30 pm that there were multiple locations where the shower and cubicle curtains did not have an NFPA 701 rating. These were: 1) the men ' s and women ' s shower in the surgical suite on the second floor, and 2) cubicle curtains in several locations on the first floor.

Based on observation the facility failed to provide an acceptable clearance around the bulk oxygen tanks.

The inspector observed while accompanied by the Director of Maintenance and the Director of Engineering during the hours of the inspection from 1:00 pm to 4:30 pm that there was parking of motor vehicles immediately adjacent to the bulk oxygen tank and H sized reserve tanks. The minimum required distance from the bulk oxygen system (this includes the oxygen piping going into the ground on the east side of the tank), is 10 feet by NFPA 50, 2.2.12. Therefore the parking on the east side of the tank shall be move over to accommodate this code requirement.


Based on observation the facility failed to provide acceptable electrical receptacles throughout the facility at patient bed locations.

The inspector observed while accompanied by the Director of Maintenance and the Director of Engineering during the hours of the inspection from 1:00 pm to 4:30 pm that there were many locations throughout the hospital in medical/surgical and pre-operatory units that did not have hospital grade electrical receptacles at patient bed locations. Hospitals shall have hospital grade receptacles at all patient bed locations.


Based on observation of the facilities records the facility was not conducting semi-annual disaster drills.

The inspector observed while accompanied by the Director of Maintenance and the Director of Engineering during the hours of the inspection from 1:00 pm to 4:30 pm that there were no records of semi-annual disaster drills to rehearse mass casualty responses for emergency services, disaster receiving stations, or both.. At least one annual " after action report " shall be maintained. Documentation of rehearsals for the last three years shall be retained.


Based on observation of the facilities records the facility did not have a copy of the latest Fire Department Inspection Report on TDSHS form.

The inspector observed while accompanied by the Director of Maintenance and the Director of Engineering during the hours of the inspection from 1:00 pm to 4:30 pm that there was not a copy of the latest Fire Department Inspection Report on TDSHS form at the facility.


Based on observation of the facilities records the facility did not have a written agreement for fuel in the case of a disaster.

The inspector observed while accompanied by the Director of Maintenance and the Director of Engineering during the hours of the inspection from 1:00 pm to 4:30 pm that there was not a preferred customer status letter with a fuel supplier or any other acceptable written agreement with a supplier for fuel in the case of an emergency. The facility did have a plan for bringing in fuel if a storm approached, but there was no documentation of where and how the fuel would be provided.

Based on observation the facility failed to provide acceptable signage on the medical gas closet.

The inspector observed while accompanied by the Director of Maintenance and the Director of Engineering during the hours of the inspection from 1:00 pm to 4:30 pm that there was not a sign on the medical gas closet that meets the requirements of NFPA 99. The medical gas closet shall have a door labeled in the following manner:

CAUTION
Medical Gases
NO Smoking or Open Flame
Room may have Insufficient Oxygen
Open Door and Allow Room to Ventilate before Entering

Re. NFPA 99, 2002: 5.1.3.1.5