HospitalInspections.org

The inspector observed, while accompanied by one Maintenance Supervisor and two Maintenance workers during the hours of the inspection from 8:15 am to 12:15 pm on 6/05/2013 that there are following issues:
A) There was a cross corridor door (to be held open my on mag lock) was not automatically closed and latch when the fire alarm is activated at the following locations: 1) The cross corridor door between ER suite and the X ray Room.


"Doors in fire walls, hazardous areas, horizontal exits, or smoke barriers may be held open only by devices arranged to automatically close the doors upon the activation of the manual fire alarm system and (existing 1 or 2). 1. Local smoke detection or a complete smoke detection system and; 2. an automatic sprinkler system (if installed). LSC 12-2.11.6, 13-2.11.5 "

" Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area enclosure shall be permitted to be held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of: (a) The required manual fire alarm system and (b) Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system and
(c) The automatic sprinkler system, if installed - NFPA 18.2.2.2.6, 19.2.2.2.6, 7.2.1.8.2 "

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by one Maintenance Supervisor and two Maintenance workers during the hours of the inspection from 8:15 am to 12:15 pm on 6/05/2013 that there were penetrations not sealed in the smoke barriers at the following locations: 1) The Smoke walls. 2) The partition above the cross corridor doors during inspection.

There was smoke detector missing at the following location: 1) at the smoke barrier cross corridor door between ER suite and the LDR suite. 2) At the smoke barrier cross corridor door between the LDR suite and the patient rooms.

Based on observation the facility failed to provide acceptable lighting for the exterior exits.

The inspector observed, while accompanied by one Maintenance Supervisor and two Maintenance workers during the hours of the inspection from 8:15 am to 12:15 pm on 06/05/2013 that that there were three locations where the exit did not have at least two lamps illuminating the all exits.

Illumination of means of egress, including exit discharge, is arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness. (This does not refer to emergency lighting in accordance with section 7.8.) 19.2.8

Based on observation the facility failed to provide emergency lighting at the means of egress.

The inspector observed, while accompanied by one Maintenance Supervisor and two Maintenance workers during the hours of the inspection from 8:15 am to 12:15 pm on 6/05/2013 that there were mean of egress were not illuminated at the following buildings:
1) The Lab building. 2) The maintenance building.


See " NFPA7.9.
" Emergency lighting of at least 1? hour duration is provided in accordance with 7.9. "

Based on observation the facility failed to provide continuous illumination for Exit and directional signs.

The inspector observed, while accompanied by one Maintenance Supervisor and two Maintenance workers during the hours of the inspection from 8:15 am to 12:15 pm on 6/05/2013 that there were exit signs were not illuminated at the following buildings:
1) The Lab building. 2) The maintenance building.

See " NFPA 7.10.5 Illumination of Signs.
7.10.5.1* General.
Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.
7.10.5.2* Continuous Illumination.
Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8. "

Based on observation the facility failed to provide adequate medical gas system.

The inspector observed, while accompanied by one Maintenance Supervisor and two Maintenance workers during the hours of the inspection from 8:15 am to 12:15 pm on 06/05/2013 that there was the following issues.

A.) It was that there was incorrect signage at the nitrous closet door.

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

See NFPA 99, 2002: 5.1.3.1.5.

Based on observation the facility failed to provide adequate receptacles.

The inspector observed, while accompanied by one Maintenance Supervisor and two Maintenance workers during the hours of the inspection from 8:15 pm to 12:15 pm on 6/05/2013 that there was the following issue: (1). There was a missing battery powered lighting units and a missing receptacle powered from life safety branch at the essential automatic transfer switch at the electrical room. (2). There was a missing battery powered lighting units and a missing receptacle powered from life safety branch at the essential automatic transfer switch at the generator location.

" The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location and essential automatic transfer switch location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

Based on observation the facility failed to provide the latest Fire Department Inspection Report on TDSHS form. This is required of all hospitals.

The inspector observed, while accompanied by one Maintenance Supervisor and two Maintenance workers during the hours of the inspection from 08:15 am to 12:15 pm on 6/5/2013 that there are the following issues:

A) The hospital was not being inspected by a local authority. If the local authority is not able to do the inspection then the hospital may be inspected by the State Fire Marshall ' s office.
B) The facility failed to provide a history of records for receptacle testing per NFPA 99: 3-3.3.3. in patient care areas.

" Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). "

" NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, ?133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984). "