HospitalInspections.org

Findings: Applicable to 4207 Burnet Road location.
The surveyor observed, while accompanied by the Directors of Plant Operations, during the hours of the survey from 10am-12pm and 1pm-3:30pm on 09/06/19 that there were the following issues:

1) Based on observations the facility failed to maintain the fire rated doors on the third floor of the NICU suite. There were visible signs of damage on the surfaces of the doors.

Findings: Applicable to 4207 Burnet Road location.
The surveyor observed, while accompanied by the Directors of Plant Operations, during the hours of the survey from 10am-12pm and 1pm-3:30pm on 09/06/19 that there were the following issues:

1) There were unsealed penetrations in the electrical closet by the third floor nursing station opposite the public elevators. Please note, "all penetrations in smoke barriers and fire walls should be sealed on both sides of the wall."
2) There were unsealed penetrations in the first floor electrical room. Please note, "all penetrations in smoke barriers and fire walls should be sealed on both sides of the wall."

Findings: Applicable to 4207 Burnet Road location.
The surveyor observed, while accompanied by the Directors of Plant Operations, during the hours of the survey from 10am-12pm and 1pm-3:30pm on 09/06/19 that there were the following issues:

1) There was wide fluctuation in temperature and humidity throughout the facility. Please refer to ASHRAE 170 for acceptable temperature and humidity ranges.

Findings: Applicable to 4681 College Park Drive.
The surveyor observed, while accompanied by the Director of Quality and Plant Operation Tech, during the hours of the survey from 9am - 12:15 pm on 09/05/19 that there were the following issues:

1) Based on observation on first floor mechanical room, the facility failed to maintain separation of dissimilar metal from contact.

"Hangers and supports shall comply with and be installed in accordance with MSS SP-58, Pipe Hangers and Supports - Materials, Design, Manufacture, Selection, Application, and Installation." - NFPA 99, 2012, 5.1.10.11.4.2

"In potentially damp locations, copper tube hangers or supports that are in contact with the tube shall be plastic-coated or otherwise be electrically insulated from the tube by a material that will not absorb moisture." - NFPA 99, 2012, 5.1.10.11.4.4

Findings: Applicable to 4207 Burnet Road location.
The surveyor observed, while accompanied by the Directors of Plant Operations, during the hours of the survey from 10am-12pm and 1pm-3:30pm on 09/06/19 that there were the following issues:

1) GFCI receptacle in patient bathroom 215 and 221 had cracks.

Findings: Applicable to both locations.
The surveyor observed, while accompanied by the Directors of Plant Operations, during the hours of the survey from 10am-12pm and 1pm-3:30pm on 09/06/19 that there were the following issues:
1) Based on review of the records, facility did not perform any receptacle maintenance and testing at all in patient care areas. NFPA 99-2012, section 6.3.3.2 lists the minimum requirements for receptacle testing regardless of hospital-grade or not. Describe the facility justification of testing frequency (e.g. appropriate testing intervals) based on documented performance data. For example, experiential data shows that retention force of the grounding blade of each electrical receptacle decreases over time due to repeated usage. Thus, the failure rate has a direct correlation to time and usage. What data does the facility collect or will implement that could provide the kind of indication of pending failures or reveal non-conformance receptacles such that it could take pre-emptive action before the onset of failure?

Findings: Applicable to 4207 Burnet Road location.
The surveyor observed, while accompanied by the Directors of Plant Operations, during the hours of the survey from 10am-12pm and 1pm-3:30pm on 09/06/19 that there were the following issues:

1) Based on observation the facility failed to provide permanent label for critical panel "3EM" on third floor sub-nursing station.