HospitalInspections.org

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

The inspector observed, while accompanied by The CEO, The Chief Nursing Officer, The Director of Nurse, and The facility Manager during the hours of the inspection from 9:00 AM to 5:00 PM on 08/26/2015 that there was the following issues:

A.)There was missing fire rated sealant/ caulking missing at one of the above ceiling of the fire rate and smoke barrier cross corridor door.
B.) There were missing astragals at various the cross corridor doors located at the smoke barrier partition.

The inspector observed, while accompanied by The CEO, The Chief Nursing Officer, The Director of Nurse, and The facility Manager during the hours of the inspection from 9:00 AM to 5:00 PM on 08/26/2015 that there was the following issues:

A.) The normal power main distribution panel did not have one hour fire rated enclosure and fire rated sealant / caulk, and did not have fire rated door and closer.
B.) The Medical Gas Room did not have one hour fire rated enclosure and fire rated sealant / caulk.
C.) There were some penetration was not sealed by the fire rated sealant at the Fire Pump Room.

Based on observation the facility failed to maintain the fire alarm system operation.

The inspector observed, while accompanied by The CEO, The Chief Nursing Officer, The Director of Nurse, and The facility Manager during the hours of the inspection from 9:00 AM to 5:00 PM on 08/26/2015 that there was the following issues:

A.) An Audible and visible fire alarm notification device (fire strobe) need to be installed inside the OR waiting room, Business office, and the pharmacy room.


" 9.6.3.10.1 Audible and visible fire alarm notification appliances shall be used only for fire alarm system or other emergency purposes. "

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

The inspector observed, while accompanied by The CEO, The Chief Nursing Officer, The Director of Nurse, and The facility Manager during the hours of the inspection from 9:00 AM to 5:00 PM on 08/26/2015 that there was the following issues:


A.) There was no signage provided at the two gates of the medical gas bulk storage tank area. Provide the following signage:

Re. NFPA 99, 2002: 5.1.3.1.5. The door shall have the following label:

CAUTION
Medical Gases
NO Smoking or Open Flame
B.) The electrical junction box and the fire alarm pull / junction box were below 5 ' -0 " A.F.F. Please relocation these electrical device above 5 ' -0 " A.F.F.
C.) There was not isolation between the medical gas pipes and the metal support at the mechanical room and the electrical plant.
D.) There was no label for the vacuum pump air flow direction.

The inspector observed, while accompanied by The CEO, The Chief Nursing Officer, The Director of Nurse, and The facility Manager during the hours of the inspection from 9:00 AM to 5:00 PM on 08/26/2015 that there was the following issues:



1) The Grounding system testing at inpatient areas on TDSHS form were not performed.
2) Line isolation monitor (Grounding system testing on TDSHS form) - the facility did not provide adequate history of inspection logs.
3) The letters indicating preferred customer status report in case of emergency situation for water and fuel source was not available.
4) Fire department inspection certificate was not available.
5) The HVAC filter change logs - the facility did not provide adequate history of inspection/ change logs.
6) Fire Drill - - the facility did not provide adequate history of fire drill logs for three shifts quarterly.
7) The Biomedical electrical semi-annual and annual inspection - the facility did not provide adequate history of inspection/ change logs.

The inspector observed, while accompanied by The CEO, The Chief Nursing Officer, The Director of Nurse, and The facility Manager during the hours of the inspection from 9:00 AM to 5:00 PM on 08/26/2015 that there was the following issues:

A.) At the essential transfer switch location there was a missing electrical outlet powered from the life safety 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 transfer switch location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.