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

The inspector observed, while accompanied by the Plant operator and the Maintenance personnel during the hours of the inspection from 10:50 am to 1:30 pm on 02/13/2014 that there were the following issues.

There were penetrations not sealed in the smoke barriers at the following locations: 1) the walls above the smoke barrier cross corridor doors located between patient wing and pediatric patient wing. 2) The walls above the smoke barrier cross corridor doors at the west wing. 3) The walls above the smoke barrier cross corridor doors at the laboratory entrance.

There were door astragals missing at the following locations: 1) at all smoke barrier cross corridor doors.

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

The inspector observed, while accompanied by the Plant operator and the Maintenance personnel during the hours of the inspection from 10:50 am to 1:30 pm on 02/13/2014 that there were the following issues. They were the following issues.

A.) Based on observation the facility failed to provide individual chains for the medical gases bottles. This does not comply with the following NFPA code. " Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. " - NFPA 99, 1999: 4-3.1.1.1.

B.) Also, the inspector observed, there were vehicles parked within 10 feet of the bulk oxygen tank enclosure.

" The minimum distance from any bulk oxygen system to any public sidewalk or parked vehicle shall be 10 ft. " - NFPA 50, 2001, 2.2.12.

Based on observation the facility failed to provide adequate receptacles and battery powered lighting units.

The inspector observed, while accompanied by the Plant operator and the Maintenance personnel during the hours of the inspection from 10:50 am to 1:30 pm on 02/13/2014 that there were the following issues. They were the following issues.

1). There was a missing battery powered lighting units and a missing receptacle powered from life safety branch at a) the essential automatic transfer switch location.

2) Identify the building exit powered operated doors are powered form life safety branch and the nursery, crash cart etc receptacles and nurse call systems are powered from the critical branch.

" 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.

Only those items listed in NFPA 70, 517.32 are allowed to be placed on the life safety branch of the essential electrical system - NFPA 70, 517.32.
The life safety branch of the essential electrical system shall supply power for the following: 1) illumination of means of egress, 2) exit signs and exit direction signs, 3) fire alarm and medical gas alarm, 4) hospital communication systems where used for emergency conditions, 5) generator set location that includes task illumination, battery charger for battery-powered lighting, and selected receptacles, 6) elevator cab lighting, control, communication, and signal systems, 7) automatic doors used for building egress, and 8) auxiliary functions of the fire alarm combination systems complying with NFPA 72. No other functions than those listed above shall be connected to the life safety branch, NFPA 99, 2002, 4.4.2.2.2.2.

The nurse call system shall be on the critical branch of the emergency electrical system - NFPA 70, 517.33 (A)(5).

Crash carts shall be on the critical branch of the emergency electrical system. Receptacles and selected power circuits needed for effective facility operation shall be on the critical branch - NFPA 99, 2002, 4.4.2.2.2.3(9).

Based on observation the facility failed to provide the Grounding system report for inpatient care areas and the Line Isolation Monitor Tests report on TDSHS form. This is required of all hospitals.

The inspector observed, while accompanied by the Plant operator and the Maintenance personnel during the hours of the inspection from 10:50 am to 1:30 pm on 02/13/2014 that there were the following issues. They were the following issues.

A) The facility failed to provide a history of records for receptacle testing at inpatient care areas and the Line Isolation Monitor per NFPA 99: 3-3.3.3. in patient care areas.
B) The facility failed to provide a letter indicating preferred customer status in case of emergency for water and fuel source.

" 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). "