HospitalInspections.org

Based on observation the facility failed to provide adequate separation between the hospital and the adjacent clinic.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 12:45 pm to 3:15 pm on 3/7/1012 that there were the following issues. There was not a 2 hour wall to deck between the hospital and the clinic. In addition, the doors in this wall were unrated, hallow core doors.

Based on observation the facility failed to provide adequate interior finishes.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 12:45 pm to 3:15 pm on 3/7/1012 that there was the following issue. In the portion of the hospital north of the smoke barrier the lower half of the walls was covered with a plastic laminate over masonite type board. There was no documentation of the flame spread of this material that is assumed to be class C or greater.

Based on observation the facility failed to provide adequate protection of the corridors.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 12:45 pm to 3:15 pm on 3/7/1012 that there was the following issue with the corridor separation. In the portion of the hospital that was not fire sprinklered, the walls did not go to the deck.

Based on observation the facility failed to provide adequate an adequate door in a corridor.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 12:45 pm to 3:15 pm on 3/7/1012 that there was the following issue. There was a dutch door in the lab that did not have a proper latch on the upper section of the door, such that the door will latch on its own when closed.

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

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 12:45 pm to 3:15 pm on 3/7/1012 that there were the following issues. They were: 1) at the cross corridor doors at the ER Lobby, 2) at the cross corridor door to the kitchen, and 3) at the cross corridor door to the clinic.

Based on observation the facility failed to provide adequate separation for hazardous areas.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 12:45 pm to 3:15 pm on 3/7/1012 that there were the following hazardous areas that did not have a door closer. They were: 1) x-ray storage, 2) soiled utility , 3) IV storage room, 4) storage room 125, 5) storage room 124, 6) storage room 123, 7) storage room 121, and 8) the storage room adjacent to the phlebotomy room did not have a closer or a latch that would allow the door to close and latch on its own.

Based on observation the facility failed to provide adequate illumination at the exterior exits.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 12:45 pm to 3:15 pm on 3/7/1012 that there were the following exterior exits that did not have two sources of illumination. They were: 1) the exit foyer, 2) the exit adjacent to the hospital business office, and 3) the exit for the west wing on the south side of the building.

Based on observation the facility failed to provide an adequate fire plan.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 12:45 pm to 3:15 pm on 3/7/1012 that the fire plan was not complete. Please see the following.

For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warm other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detained in the facility ' s fire safety plan. A written fire safety plan shall provide for the following: (1) Use of alarms, (2) Transmission of alarm to fire department, (3) Response to alarms, (4) Isolation of fire., (5) Evacuation of immediate area, (6) Evacuation of smoke compartment, (7) Preparation of floors and building for evacuation, and (8) Extinguishment of fire. - NFPA 101, 2000, 19.7.2. This is often summarized by the use of the acronym RACE. This stands for Rescue/Respond, Alarm, Contain, and Evacuate.

Based on observation the facility failed to provide adequate cross referencing between the FACP and the panel and breaker supplying power to the FACP.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 12:45 pm to 3:15 pm on 3/7/1012 that there were the following issues. They were: 1) the FACP did not have a label indicating the panel and breaker supplying power to the FACP, and 2) the panel and breaker supplying power to the FACP did not have a red breaker for the FACP, the breaker must be labeled " FIRE ALARM " , and the panel directory was not up to date. In addition, the electrical panel itself did not have a designation.

Based on observation the facility failed to provide adequate clearance below the sprinkler heads.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 12:45 pm to 3:15 pm on 3/7/1012 that there was the following issue in the central supply storage room. The storage shelves in the center of the room were higher than the plane defined by 18 " below the level of the fire sprinkler shields.

Based on observation the facility failed to provide adequate clear corridors.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 12:45 pm to 3:15 pm on 3/7/1012 that there was the following issue with a corridor. In the corridor adjacent to the lab there were two residential grade couches placed against the corridor wall but obstructing the overall clearance.

Based on observation the facility failed to secure the medical gas bottles.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 12:45 pm to 3:15 pm on 3/7/1012 that there was the following issue. The oxygen cylinders in the exterior enclosure were not individually secured to the walls, and in some cases were not secured at all.

Patient care related electrical appliances shall be retested at intervals determined by their normal location or area of normal use, but not exceeding the intervals listed below: General Care Areas - 12 months, Critical Care Areas - 6 months. - NFPA 99, 1999, 7-6.2.1.2.

Based on observation the facility failed to provide an acceptable history of electrical appliance testing in critical areas.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 12:45 pm to 3:15 pm on 3/7/1012 that the critical equipment in the E.R. was not being retested twice a year.


NFFA 99, 1999, 3-3.3.3 Receptacle Testing in Patient Care Areas
(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. If the facility has documented performance data for the electrical receptacles in all patient care areas then the schedule defined by this data will be acceptable. In the absence of the data the following schedule shall be maintained by the facility. Receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

Based on observation the facility failed to provide a history of records for retention force.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 12:45 pm to 3:15 pm on 3/7/1012 that there were not records of retention force testing. That is annually in regular patient care areas and twice a year in the E.R.


Based on observation the facility failed to provide a letter from a vendor for emergency water indicating that they have a preferred customer status.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 12:45 pm to 3:15 pm on 3/7/1012 that there was no letter from a vendor for water indicating that the hospital has preferred customer status re. NPFA 99, 11-5.3.2.


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 the Plant Manager during the hours of the inspection from 12:45 pm to 3:15 pm on 3/7/1012 that 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.