HospitalInspections.org

Based on observations made during the survey of the facility between the hours of 1:30 pm and 6:30 pm, while accompanied by the CEO, Facilities Director, Chief Nursing Officer, and the Improvements Coordinator it was observed that while it appears the facility had accomplished some of the requirements, the facility failed to satisfy the following issues and items:

1. Log indicating consistent, systematic compliance on
a. Electrical power and distribution and grounding systems - Effectiveness.
Critical Areas: Semi-annually.
General Areas: Annually

2. Unconventional Construction For Level 2 - There is a large 2nd Floor level (several thousand square feet) for this facility which is not occupied, nor is it constructed to be in compliance to be occupied. It is very confusing as to what " use " , " purpose " , and " occupancy " was intended to be served by this oddly conceived design and construction of a 2nd Floor which contains the following issues and characteristics:
a. NO ELEVATOR - There is no elevator between floors, but there are 2 sets of stairs.

b. NO FIRE/SMOKE SEPARATION CONSTRUCTION AT EXIT STAIRS - Neither of the 2 stairs were constructed in compliance with the fire/smoke separation typically required for " Exit Stairs " . There are no fire-rated partitions constructed around the stairs to separate them from the 2nd floor. There are no doors separating the stairs from Level 2.

c. UNDECLARED INTENT ON TYPE OF OCCUPANCY & UNCLEAR WHETHER 1 HOUR OR 2 HOUR SEPARATION CONSTRUCTION IS REQUIRED - One stair is reasonably near an exterior Exit door on 1st floor, but the 2nd stair empties out into a large CENTRAL SUPPLY room (Level 1) which must be crossed in order to reach a door leading to a " means of egress Corridor which then leads to an exterior exit.

If the upstairs portion is to be classified as a different occupancy from the Hospital ' s I-2 OCCUPANCY, then the fire separation requirement would have to be rated at 2 hours, and the " Exit Stair " would not be allowed to exit into the CENTRAL SUPPLY room of the I-2 OCCUPANCY.

d. LEVEL 2 FLOORING BUILT AT DIFFERENT ELEVATIONS - Large portions of the upper level structural floor deck are constructed at a different and lower elevation - approximately 18 inches below the main 2nd floor level, and there are no ramps or steps for traversing the level changes.

e. SECTIONS OF LEVEL 2 MISSING CONCRETE AT STRUCTURAL DECK - There are small portions of the 2nd floor structural deck which have exposed structural metal decking with no concrete over the metal deck that do not appear to offer the required fire separation from the 1st floor level.

f. NON-RATED EXIT STAIR CONSTRUCTION - There are 2 stairs that are not constructed in compliance with " Exit Stair " requirements since there is no 1 hour fire separation construction around the stairs to separate them from both the 1st and 2nd floor areas.

g. NON-COMPLIANCE WITH MEANS OF EGRESS REQUIREMENTS - One of the stairs is near an exterior Exit door on 1st floor, but the other one comes down from 2nd floor and empties out into a large CENTRAL SUPPLY room which must be crossed in order to reach a door leading to an " means of egress Corridor that leads to an exterior exit.

h. NO EXIT SIGNAGE FOR LEVEL 2 - There is no Exit Signage on Level 2.

3. For the present time provide adequate signage to direct staff that: "LEVEL 2 SHALL NOT BE UTILIZED AS OCCUPIED SPACE, OR AS STORAGE SPACE."
4. There were 7 Air Handlers located on the roof that were determined to serve PATIENT CARE AREAS. None of the 7 units had the required final filter bed. This will need to be submitted to TDSHS as a separate construction project.