(a) The governing body shall appoint a safety officer who is knowledgeable in safety practices in health care facilities. The safety officer shall carry out the functions of the safety program.     
      (b) Safety activities.      
        (1) The safety officer shall establish an incident reporting system which includes a mechanism to ensure that all incidents recorded are evaluated, and documentation is provided to show follow-up and corrective actions.       
        (2) Safety policies and procedures for the facility shall be developed, implemented, and enforced.       
        (3) Safety training shall be established as part of new employee orientation and in the continuing education of all employees.       
      (c) The authority of the safety officer to take action, when conditions exist that are a possible threat to life, health, or building damage, shall be defined in writing and approved by the governing body.     
      (d) Each department or service shall have a safety manual describing safety policies and procedures within their own areas and become part of the overall facility safety manual.     
      (e) An emergency communication system, such as radio-frequency communication devices, battery operated emergency phone, or cellular telephones, shall be provided in each facility. The system shall be self-sufficient and capable of operating without reliance on the building's service or emergency power supply. Such system shall have the capability of communicating with the available community or state emergency networks, including police and fire departments.     
      (f) No portable or ceiling fans shall be utilized in any patient treatment areas, exam areas, holding areas, imaging areas, diagnostic areas, clean and sterile environments.     
      (g) Electrical extension cords and cables shall not be used for permanent wiring. When temporary electrical cords or cables are used, they shall be secured and protected to prevent tripping.     
      (h) A nurse's emergency calling system shall be installed in the all treatment room/area station(s), exam rooms/area station(s), isolation room(s), patient holding stations, imaging, diagnostic and patient toilet room(s) to summon nursing staff in an emergency. Activation of the system shall sound a distinct audible signal which repeats every five seconds or less at the nurse station, indicate type and location of call on the system monitor, and activate a distinct visible signal in all areas. The activation of the system shall also activate distinct visible signals in the clean workroom, soiled workroom, and if provided, in the nourishment station. The visible and audible signals shall be cancelable only at the patient calling station. A nurse's emergency call system shall be accessible to a collapsed patient lying on the floor. Inclusion of a pull cord extending to within 6 inches of the floor will satisfy this requirement.     
      (i) A staff emergency assistance calling system station shall be located in each treatment room/area, examination room/area, trauma room/area, and holding room/area to be used by staff to summon additional help in an emergency. Activation of the system shall sound an audible signal at a staffed location, indicate type and location of call on the system monitor, and activate a distinct visible signal in the corridor at the door. Additional visible signals shall be installed at corridor intersections in multi-corridor facilities. Distinct visible and audible signals shall be activated in the clean workroom, in soiled workroom, equipment storage, and if provided, in the nourishment station.     
      (j) Doors to any treatment, exam, or isolation rooms shall not be lockable from inside the room.     
      (k) When construction takes place during any treatments, exams, and diagnostics, adequate provision shall be made for the safety and comfort of patients. Temporary sound barriers shall be provided where intense prolonged construction noises will disturb patients or staff in the occupied portions of the building during patient treatment times.     
      (l) When construction occurs after hours or on weekends, the facility shall thoroughly clean all areas of construction and provide a clean safe environment before treating patients.     
      (m) A facility shall provide a physical environment that protects the health, safety, and welfare of patients, personnel, and the public. The physical premises and the environment of the facility and those areas of the facility's surrounding physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes as they relate to safe access and patient privacy.     
     Source Note:        The provisions of this §131.122 adopted to be effective June 1, 2010, 35 TexReg 4400