HospitalInspections.org

The inspector observed, while accompanied by the Director, Director of Safety and Security, Executive Vice President Integration and Business Development, Assistant Director of Plant Operations, and Maintenance Technician, during the hours of the inspection from 10:00AM to 6:00 PM on 07/22/2015 and 8:30 AM to 7:00 PM on 07/23/2015, that there were the following issues:

A) Observed throughout the entire hospital. The access panel for damper was missing labeling.

"All access panels for dampers shall be labeled in accordance with the requirements of NFPA 90A, 2002: 4.3.4.1 through 4.3.4.2. A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device. Service openings shall be identified with letters having a minimum height of ½ inch to indicate the location of the fire protection device(s) within. " -NFPA 90A, 2002: 4.3.4.1 & 4.3.4.2

The inspector observed, while accompanied by the Director, Director of Safety and Security, Executive Vice President Integration and Business Development, Assistant Director of Plant Operations, and Maintenance Technician, during the hours of the inspection from 10:00AM to 6:00 PM on 07/22/2015 and 8:30 AM to 7:00 PM on 07/23/2015, that there were the following issues:

A) Observed in East tower, 3rd floor, Storage Room. There was no door closer.
B) Observed in main hospital, 4th floor, patient room 1430. Patient room 1430 was used by the nursing staff as a storage room, however, it lacked the necessary fire rated door and door closer.
C) Observed in main hospital, 2nd floor, NICU area, S2 Equipment Storage Room. There was no door closer. This was corrected on site.
D) Observed in main hospital, 6th floor, pharmacy room. The existing pharmacy room was converted into a clean storage room. Therefore, it is subject to hazardous area requirements which include fire rated door and door closer.

" Doors to hazardous areas shall be self-closing or automatic-closing in accordance with 10.2.2.3. " -NFPA 101, 2003, 20.3.2.1.

The inspector observed, while accompanied by the Director, Director of Safety and Security, Executive Vice President Integration and Business Development, Assistant Director of Plant Operations, and Maintenance Technician, during the hours of the inspection from 10:00AM to 6:00 PM on 07/22/2015 and 8:30 AM to 7:00 PM on 07/23/2015, that there were the following issues:

A) Observed in the main hospital, 3rd floor, electrical room. There were rubbish and construction supplies left in the electrical room. This was correct on site.
B) Observed in main hospital, ground floor, electrical room 1007. There were rubbish and construction supplies in the room and thus contributed to hazard of contents.

" Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4. " - NFPA 101, 2000, 39.3.2.1.

The inspector observed, while accompanied by the Director, Director of Safety and Security, Executive Vice President Integration and Business Development, Assistant Director of Plant Operations, and Maintenance Technician, during the hours of the inspection from 10:00AM to 6:00 PM on 07/22/2015 and 8:30 AM to 7:00 PM on 07/23/2015, that there were the following issues:

A) Observed in the main hospital, ground floor, maintenance room located next to the Emergency Department. There was storage of items above an 18 inch plane below the sprinkler head shields.
B) Observed in main hospital, ground floor, fire pump room. The valve tags were damaged due to age and environmental factors and therefore not legible.

" A minimum clearance of 18 inches shall be maintained between the top of storage and sprinkler deflectors " - NFPA 13, 2002: 8.5.6.1.

" All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. " - NFPA 13, 2002: 6.7.4.1. " The control valve sign shall identify the portion of the building served. " - NFPA 13, 2002: 6.7.4.3.

The inspector observed, while accompanied by the Director, Director of Safety and Security, Executive Vice President Integration and Business Development, Assistant Director of Plant Operations, and Maintenance Technician, during the hours of the inspection from 10:00AM to 6:00 PM on 07/22/2015 and 8:30 AM to 7:00 PM on 07/23/2015, that there were the following issues:

A) Observed in main hospital, 6th floor, med gas zone valve location. The pressure gage reading for air was above 100 psi. This value was not consistent with other readings throughout the facility.
B) Observed in main hospital, 2nd floor, med gas zone valve box serving Physicians Sleep, Special Care Nursery & Room 1279. The mechanical pressure gage and the digital readout readings for the vacuum did not match. Proper functioning of these devices are integral to the usefulness of the med gas alarm system.

" The master alarm system shall consist of two or more alarm panels located in at least two separate locations: (1) One master alarm panel shall be located in the office or work space of the individual responsible for the maintenance of the medical gas and vacuum piping systems. (2) In order to assure continuous surveillance of the medical gas and vacuum systems while the facility is in operation the second master alarm panel shall be located in an area of continuous observation (e.g., the telephone switchboard, security office, or other continuously staffed location.) " - NFPA 99, 2002, 5.1.9.2.1.

K0130 Dietary

The inspector observed, while accompanied by the Director, Director of Safety and Security, Executive Vice President Integration and Business Development, Assistant Director of Plant Operations, and Maintenance Technician, during the hours of the inspection from 10:00AM to 6:00 PM on 07/22/2015 and 8:30 AM to 7:00 PM on 07/23/2015, that there were the following issues:

A) Observed in main hospital, 2nd floor, kitchen area. The hospital did not provide adequate clearance between the deep fryer and the cooking top unit.

" All deep fat fryers shall be installed with at least a 16 inch space between the fryer and surface flames from adjacent cooking equipment. " 2001 NFPA 96, 12.1.2.4.

K0130 ASHRAE Pressure Relationships between Rooms
The inspector observed, while accompanied by the Director, Director of Safety and Security, Executive Vice President Integration and Business Development, Assistant Director of Plant Operations, and Maintenance Technician, during the hours of the inspection from 10:00AM to 6:00 PM on 07/22/2015 and 8:30 AM to 7:00 PM on 07/23/2015, that there were the following issues:

A) Observed in main hospital, 5th floor, patient bathroom room 1501. The bathroom exhaust fan was not operational. This was corrected on site.

The pressure relationships between spaces are essential for odor and infection control. NFPA 101 references all NFPA publications. Chapter 6 of NFPA 90A, 1999 references ASHRAE documents as a mandatory part of the requirements of the standard. Current ventilation tables are given by ANSI/ASHRAE/ASHE Standard 170. In addition, State Licensing Regulations control pressure relationships. Patient bathrooms shall be negatively pressurized relative to adjacent spaces.

K0130 Occupancy Separation
The inspector observed, while accompanied by the Director, Director of Safety and Security, Executive Vice President Integration and Business Development, Assistant Director of Plant Operations, and Maintenance Technician, during the hours of the inspection from 10:00AM to 6:00 PM on 07/22/2015 and 8:30 AM to 7:00 PM on 07/23/2015, that there were the following issues:

A) Observed in main hospital, ground floor and first floor. Select Specialty Company, a tenant of Good Shepherd Medical Center, operates as a nursing care, does not have a 2-hour separation from the hospital. In addition, verify that Select Specialty Company has a separate, independently operated nurse calling system. An on-site inspection from the Department of State Health Services (DSHS) Architectural Review Group will be required subsequent to the completion of this deficiency correction.

"Where separated occupancies are provided, each part of the building comprising a distinct occupancy, as described in this chapter, shall be completely separated from other occupancies by fire-resistive assemblies as specified in 6.1.14.4.2, 6.1.14.4.3, and Table 6.1.14.4.1, unless separation is provided by approved existing separations. " - NFPA 101, 2003, 6.1.14.4.1.

" Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions: (1) They are not intended to serve health care occupants for purposes of housing, treatment, or customary access by patients incapable of self-preservation. (2) They are separated from areas of health care occupancies by construction having a fire resistance rating of not less than 2 hours. " - NFPA 101, 2003, 19.1.2.2

" The following equipment and systems shall be provided for the exclusive use of the hospital, except where noted otherwise: - (XI) nurses calling systems. " - H.L.R., 2007: §133.165(b)(1)(C)(i).