HospitalInspections.org

1. Based on observation and interview, the facility failed to ensure 1 of 30 ground floor corridor doors and 7 of 70 first floor corridor doors did not have an impediment to closing. This deficient practice could affect any patient as well as staff and visitors on the ground or first floor of the hospital.

Findings include:

Based on observation with the Facilities Director during a tour of the facility on 03/17/14 from 10:45 a.m. to 12:45 p.m. and then from 1:15 p.m. to 2:45 p.m., the following was noted:
a. The Dutch door of the Data Processing/Information Technology office had a piece of foam rubber taped over the latching device of the door.
b. The doors to the Gift Shop, Cardiopulmonary # 1, # 2, # 3, the Cardiopulmonary office, the Radiologist's Reading room and the CTS scan room were propped open by metal kick-down doorstops attached to the bottom of the doors. Based on interview at the time of observation, the Facilities Director acknowledged the doors were propped open with the attached door stops.


10595

2. Based on observation and interview, the facility failed to ensure 3 of 90 second floor room doors would resist the passage of smoke with no impediment to closing the doors. This deficient practice affects two patients who reside in room number 270 and 272, and 4 patients on the East Obstetric Hall, located near the nurse supervisor office.

Findings include:

Based on observations on 03/17/14 during a tour of the second floor with the Bio-Medical Engineer from 9:45 a.m. to 12:45 p.m., patient room numbers 270 and 272 each had a metal kickstand screwed to the bottom of the room doors which were propped open. Furthermore, the East Obstetrics Hall Nurse Supervisor office door had four, one half inch circular holes through the top of the nonlatching side of the door. The metal kickstands attached to the doors of patient rooms 270 and 272 and the holes in the door to the nurse supervisor room office were verified by the Bio-Medical Engineer at the time of observations.

Based on observation and interview, the facility failed to ensure 1 of 4 stairways, a vertical opening, was enclosed with construction having a fire resistance rating of at least one hour. This deficient practice could affect any patient residing on the Medical Surgery Hall who would use the medical surgery center stairway for evacuation.

Findings include:

Based on observation on 03/17/14 at 12:05 p.m. with the Bio-Medical Engineer, the center medical surgery stairway wall outside the third floor elevator equipment room had a three inch diameter circular opening in the stairway wall between the stairway and the elevator equipment room with no fire stopping material used to seal the opening. This was verified by the Bio-Medical Engineer at the time of observation.

Based on observation and interview, the facility failed to ensure 2 of 90 second floor room wall smoke barriers were maintained to provide a one half hour fire resistance rating. LSC 8.3.2 requires smoke barriers shall be continuous from an outside wall to an outside wall. This deficient practice could affect any patient using ambulatory heath care and obstetrics.

Findings include:

Based on observations with the Bio-Medical Engineer on 03/17/14 during a tour of the second floor Ambulatory Health Care Hall and Obstetrics Hall from 10:10 a.m. to 11:45 a.m., the Ambulatory Health Care Hall data closet north wall had a six inch by one inch open area above the electric panel with no drywall, and the Obstetrics Hall mechanical room number ABHU4 south wall had a two inch circular opening around a cable bundle which was not fire stopped and a three foot open area with the drywall missing. This was verified by the Bio-Medical Engineer at the time of observations.

Based on observation and interview, the facility failed to ensure the corridor door to 1 of 6 hazardous areas, such as combustible storage room over 50 square feet in size would automatically close and latch into the door frame. This deficient practice could affect any patient on the Medical Surgery Hall.

Findings include:

Based on observation on 03/17/14 at 10:20 a.m. with the Bio-Medical Engineer, the Medical Surgery Hall surgery storage room which measured two hundred sixty square feet in size and stored combustible cardboard boxes of paper supplies and plastic surgery equipment had a metal kickstand screwed to the bottom of the door which propped the room door open and prevented the self closing device from automatically closing and latching the door. This was verified by the Bio-Medical Engineer at the time of observation.

1. Based on observation and interview, the facility failed to ensure 3 of 4 first floor exits which continued more than one half story beyond the level of exit discharge, were interrupted at the level of exit discharge by partitions, doors, or other effective means.
LSC 7.7.3 requires the exit discharge shall be arranged and marked to make clear the direction of egress to a public way. Stairs shall be arranged so as to make clear the direction of egress to a public way. Stairs that continue more than one half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means. This deficient practice could affect all patients in the facility who would use the first floor east exit near the chiller deck, the first floor west exit near the housekeeping storage area, and the first floor north west exit near the operating room storage area.

Findings include:

Based on observations on 03/17/14 during a tour of the second floor with the Bio-Medical Engineer from 9:45 a.m. to 12:45 p.m., the second floor Sleep Center Hall stairway exit, the second floor Patient Hall stairway exit, and the second floor Obstetrics Hall stairway exit discharged into enclosed stairways to the first floor and exited into the parking lot. Furthermore, the three first floor exit stairways continued to the basement and lacked stairway interrupters at the first floor level of discharge. This was verified by the Bio-Medical Engineer at the time of observations.

2. Based on observation and interview, the facility failed to ensure 1 of 4 second floor exit accesses leading to the first floor discharge path with stairs was provided with a handrail. LSC 7.2.2.4.2 requires stairs and ramps shall have handrails on both sides. In addition, handrails shall be provided within 30 inches of all portions of the required egress width of stairs. The required egress width shall be provided along the natural path. Exception No 3: Existing stairs, existing ramps, stairs within dwelling units and within guest rooms, and ramps within dwelling units and guest rooms shall be permitted to have a handrail on one side only. This deficient practice could affect any patients using the second floor Obstetrics Hall East stairway exit enclosure during an evacuation.

Findings include:

Based on observation on 03/17/14 at 12:15 p.m. with the Bio-Medical Engineer, the second floor Obstetrics Hall East stairway discharged to the first floor East Wing exit onto an asphalt sidewalk. Furthermore, the sidewalk surface extended fifteen feet to two stairs and up to a twelve foot landing with one stair on the opposite side of the landing and onto the parking lot. The stairs on both sides of the landing lacked a handrail. The lack of handrail on each side of the fifteen foot sidewalk landing was verified by the Bio-Medical Engineer at the time of observation.

1. Based on observation and interview, the facility failed to replace 1 of over 300 second floor sprinklers covered in brown corrosion. LSC 9.7.5 requires all automatic sprinkler systems shall be inspected, tested and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 1998 edition, 2-2.1.1 requires any sprinkler shall be replaced which is painted, corroded, damaged, loaded, or in the improper orientation. This deficient practice could affect any patient on the Sleep Center Hall.

Findings include:

Based on observation on 03/17/14 at 11:55 a.m. with the Bio-Medical Engineer, the Sleep Center Hall staff office closet sprinkler was completely covered in brown corrosion. This was verified by the Bio-Medical Engineer at the time of observation.


33713

2. Based on record review and interview, the facility failed to ensure 1 of 1 automatic dry sprinkler piping systems was inspected every five years as required by NFPA 25, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems 10-2.2. Section 10-2.2, Obstruction Prevention, states systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This deficient practice affects all occupants.

Findings include:

Based on record review with the Bio-Mechanical Engineer on 03/17/14 at 10:15 a.m., the Shambaugh & Son's sprinkler inspection report titled "Sprinkler Inspection Certificate" dated 02/19/14 provided a check mark in a "yes" box that an internal pipe inspection had been done. The sprinkler inspection documentation did not indicate when the most recent internal inspection of the dry sprinkler system had been done. Based on an interview with the Bio-Mechanical Engineer at the time of record review, 2009 was thought to be when the internal inspection of the dry sprinkler system had been done but specific documentation of the internal pipe inspection was not available for review.

1. Based on observation, record review, and interview; the facility failed to enforce the policy for the use of portable space heaters in the facility in accordance with NFPA 101, Section 19.7.8. This deficient practice could affect at any patient, staff or visitor throughout the hospital.

Findings include:

Based on a review of the hospital's written portable space heater policy on 03/17/14 at 9:30 a.m. with the Facilities Director, the written policy stated portable electric space heaters may be used in staff offices under supervision by facility staff, turned off when not in use, and hospital maintenance staff must approve each space heating device to ensure the heating elements do not exceed 212 degrees Fahrenheit. Based on an interview with the Facilities Director on 03/17/14 at 9:35 a.m., there was no written evidence to indicate the heating elements of the electric portable space heaters in use did not exceed 212 degrees Fahrenheit. Based on observations on 03/17/14 during a tour from 10:45 a.m. to 12:45 p.m. and then from 1:15 p.m. to 2:45 p.m., the following was noted:
a. At least three electric space heaters were observed in use in the Emergency Department (ED) at two workstations and the nurses station which were part of a patient care area.
b. An electric space heater was observed in use in the Recertification office which was open to a patient/visitor waiting area. Based on interview with the Facilities Director at the exit conference at 3:00 p.m. on 03/17/14, the facility has purchased and distributed at least sixty electric space heaters throughout the hospital and the facility does not have documentation that the heating elements of the space heaters will not exceed 212 degrees Fahrenheit.


10595

2. Based on observation, interview, and record review; the facility failed to ensure evidence was provided for portable space heating devices used in nonsleeping staff and employee areas to ensure the heating elements of the devices do not exceed 212 degrees Fahrenheit. This deficient practice could affect all patients on the second floor in the event a staff used portable space heater started fire.

Findings include:

Based on a review of the hospital's written portable space heater policy on 03/17/14 at 9:30 a.m. with the Facilities Director, the written policy stated portable electric space heaters may be used in staff offices under supervision by facility staff, turned off when not in use, and hospital maintenance staff must approve each space heating device to ensure the heating elements do not exceed 212 degrees Fahrenheit. Based on an interview with the Facilities Director on 03/17/14 at 9:35 a.m., there was no written evidence to indicate the heating elements of the electric portable space heaters in use did not exceed 212 degrees Fahrenheit. Based on observations on 03/17/14 during a tour of the second floor with the Bio-Medical Engineer from 9:45 a.m. to 12:45 p.m., the sleep center staff office, the rehabilitation gym director office, and the director services office each had a portable electric space heater in use. Based on observation of the three space heaters, there was no written information on each space heater to indicate the maximum temperature of the heating elements. The lack of written evidence the portable space heaters' heating elements did not exceed 212 degrees Fahrenheit was verified by the Bio-Medical Engineer at the time of observations.

Based on observation and interview, the facility failed to ensure the means of egress was continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency for 2 of 4 exits. This deficient practice could affect staff and visitors throughout the ground floor of the hospital.

Findings include:

Based on observation with the Facilities Director during a tour of the facility on 03/17/14 from 10:45 a.m. to 12:45 p.m. and then from 1:15 p.m. to 2:45 p.m., the following was noted:
a. The ground floor north exit stairwell had storage of a salad bar, four coolers and assorted dietary equipment obstructing the exit.
b. The dietary corridor leading to the ground floor north exit had storage of a desk, chairs, file cabinets and carts obstructing the means of egress.
c. The ground floor south exit stairwell had storage of a paint cart, paint cans, a ladder and sawhorses obstructing the exit.
Based on interview at the times of observation, the Facilities Director acknowledged the aforementioned conditions.

Based on observation, interview and record review; the facility failed to ensure the care and maintenance of 1 of 1 rolling fire doors was in accordance with NFPA 80. LSC 4.5.7 requires any device, equipment or system which is required for compliance with the provisions of this Code, such device, equipment or system shall thereafter be maintained unless the Code exempts such maintenance. NFPA 80, 1999 Edition, the Standard for Fire Doors and Fire Windows, Section 15-2.4.3 requires all horizontal or vertical sliding and rolling fire doors to be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction. This deficient practice could affect any staff or visitor using the ground floor dining room adjacent to the kitchen.

Findings include:

Based on observation on 03/17/14 during the tour from 10:45 a.m. to 12:45 p.m. with the Facilities Director, there was a rolling fire door protecting the opening from the kitchen to the main dining room without an attached inspection tag. Based on interview during paperwork review from 9:45 a.m. to 12:45 p.m. with the Facilities Director, the Facilities Director acknowledged there was no documentation of an annual inspection or test since installation to check for proper operation and full closure of the vertical rolling fire door.

Based on observation and interview, the facility failed to ensure high current draw electrical devices were not plugged into power strips as a substitute for fixed wiring. LSC 19.5.1 requires utilities to comply with Section 9.1. LSC 9.1.1 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 1999 Edition. NFPA 70, Article 400-8 requires, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could affect staff and visitors.

Findings include:

Based on observation with the Facilities Director during a tour of the facility on 03/17/14 from 1:15 p.m. to 2:45 p.m., the following was noted:
a. The Cardiopulmonary office had a microwave plugged into a power strip.
b. The Business office had a refrigerator plugged into a power strip..
c. The Recertification office had a refrigerator plugged into a power strip.
Based on interview at the times of observation, the Facilities Director acknowledged the aforementioned conditions.

Based on record review and interview, the facility failed to provide a complete written policy indicating procedures to be followed in the event the automatic sprinkler system has to be placed out of service for 4 hours or more in a 24 hour period in accordance with LSC, Section 9.7.6.1. in order to protect 14 of 14 patients. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, 1998 Edition, Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 11-5(d) requires the local fire department be notified of a sprinkler impairment and 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified. This deficient practice could affect all occupants.

Findings include:

Based on review of the facility's fire watch policy and procedure on 03/17/14 during paperwork review from 9:45 a.m. to 12:45 p.m. with the Facilities Director, the fire watch procedure for an out of service sprinkler system was not complete. The policy and procedure did not include notification to the Indiana State Department of Health which is an authority having jurisdiction. Based on interview at the time of record review, the Facilities Director acknowledged the fire watch policy and procedure did not include notification to the Indiana State Department of Health.

Based on record review and interview, the facility failed to ensure its written fire watch policy addressed all procedures to be followed in this facility in the event the fire alarm system has to be placed out of service for 4 hours or more in a 24 hour period in accordance with LSC, Section 9.6.1.8. in order to protect 14 of 14 patients. This deficient practice could affect all occupants of the facility.

Findings include:

Based on review of the facility's fire watch policy and procedure on 03/17/14 during paperwork review from 9:45 a.m. to 12:45 p.m. with the Facilities Director, the fire watch procedure for an out of service fire alarm system was not complete. The policy and procedure did not include notification to the Indiana State Department of Health which is an authority having jurisdiction. Based on interview at the time of record review, the Facilities Director acknowledged the fire watch policy and procedure did not include notification to the Indiana State Department of Health.

Based on observation and interview, the facility failed to ensure 1 of 1 alcohol based hand rub dispensers within the CTS scan room was not installed over an ignition source. This deficient practice could affect any patient within the CTS scan room.

Findings include:

Based on observation and interview on 03/17/14 with the Facilities Director during the tour from 1:15 p.m. to 2:45 p.m., the CTS scan room had an alcohol based hand rub dispenser mounted on the wall directly above an electric outlet. Based on interview with the Facilities Director, it was acknowledge the alcohol based hand rub dispenser was mounted directly above an electrical outlet.


10595

Based on observation and interview, the facility failed to ensure 1 of 20 second floor patient rooms' alcohol based hand rub dispensers was not located over an ignition source. This deficient practice could affect one patient in the Obstetrics Hall, room 240.

Findings include:

Based on observation on 03/17/14 at 11:35 a.m. with the Bio-Medical Engineer, the second floor Obstetrics Hall, room 240 had a fifteen ounce container of alcohol based hand sanitizer mounted on the west wall directly above an electric outlet. This was verified by the Bio-Medical Engineer at the time of observation.

1. Based on observation and interview, the facility failed to ensure 1 of 30 ground floor corridor doors and 7 of 70 first floor corridor doors did not have an impediment to closing. This deficient practice could affect any patient as well as staff and visitors on the ground or first floor of the hospital.

Findings include:

Based on observation with the Facilities Director during a tour of the facility on 03/17/14 from 10:45 a.m. to 12:45 p.m. and then from 1:15 p.m. to 2:45 p.m., the following was noted:
a. The Dutch door of the Data Processing/Information Technology office had a piece of foam rubber taped over the latching device of the door.
b. The doors to the Gift Shop, Cardiopulmonary # 1, # 2, # 3, the Cardiopulmonary office, the Radiologist's Reading room and the CTS scan room were propped open by metal kick-down doorstops attached to the bottom of the doors. Based on interview at the time of observation, the Facilities Director acknowledged the doors were propped open with the attached door stops.


10595

2. Based on observation and interview, the facility failed to ensure 3 of 90 second floor room doors would resist the passage of smoke with no impediment to closing the doors. This deficient practice affects two patients who reside in room number 270 and 272, and 4 patients on the East Obstetric Hall, located near the nurse supervisor office.

Findings include:

Based on observations on 03/17/14 during a tour of the second floor with the Bio-Medical Engineer from 9:45 a.m. to 12:45 p.m., patient room numbers 270 and 272 each had a metal kickstand screwed to the bottom of the room doors which were propped open. Furthermore, the East Obstetrics Hall Nurse Supervisor office door had four, one half inch circular holes through the top of the nonlatching side of the door. The metal kickstands attached to the doors of patient rooms 270 and 272 and the holes in the door to the nurse supervisor room office were verified by the Bio-Medical Engineer at the time of observations.

Based on observation and interview, the facility failed to ensure 1 of 4 stairways, a vertical opening, was enclosed with construction having a fire resistance rating of at least one hour. This deficient practice could affect any patient residing on the Medical Surgery Hall who would use the medical surgery center stairway for evacuation.

Findings include:

Based on observation on 03/17/14 at 12:05 p.m. with the Bio-Medical Engineer, the center medical surgery stairway wall outside the third floor elevator equipment room had a three inch diameter circular opening in the stairway wall between the stairway and the elevator equipment room with no fire stopping material used to seal the opening. This was verified by the Bio-Medical Engineer at the time of observation.

Based on observation and interview, the facility failed to ensure 2 of 90 second floor room wall smoke barriers were maintained to provide a one half hour fire resistance rating. LSC 8.3.2 requires smoke barriers shall be continuous from an outside wall to an outside wall. This deficient practice could affect any patient using ambulatory heath care and obstetrics.

Findings include:

Based on observations with the Bio-Medical Engineer on 03/17/14 during a tour of the second floor Ambulatory Health Care Hall and Obstetrics Hall from 10:10 a.m. to 11:45 a.m., the Ambulatory Health Care Hall data closet north wall had a six inch by one inch open area above the electric panel with no drywall, and the Obstetrics Hall mechanical room number ABHU4 south wall had a two inch circular opening around a cable bundle which was not fire stopped and a three foot open area with the drywall missing. This was verified by the Bio-Medical Engineer at the time of observations.

Based on observation and interview, the facility failed to ensure the corridor door to 1 of 6 hazardous areas, such as combustible storage room over 50 square feet in size would automatically close and latch into the door frame. This deficient practice could affect any patient on the Medical Surgery Hall.

Findings include:

Based on observation on 03/17/14 at 10:20 a.m. with the Bio-Medical Engineer, the Medical Surgery Hall surgery storage room which measured two hundred sixty square feet in size and stored combustible cardboard boxes of paper supplies and plastic surgery equipment had a metal kickstand screwed to the bottom of the door which propped the room door open and prevented the self closing device from automatically closing and latching the door. This was verified by the Bio-Medical Engineer at the time of observation.

1. Based on observation and interview, the facility failed to ensure 3 of 4 first floor exits which continued more than one half story beyond the level of exit discharge, were interrupted at the level of exit discharge by partitions, doors, or other effective means.
LSC 7.7.3 requires the exit discharge shall be arranged and marked to make clear the direction of egress to a public way. Stairs shall be arranged so as to make clear the direction of egress to a public way. Stairs that continue more than one half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means. This deficient practice could affect all patients in the facility who would use the first floor east exit near the chiller deck, the first floor west exit near the housekeeping storage area, and the first floor north west exit near the operating room storage area.

Findings include:

Based on observations on 03/17/14 during a tour of the second floor with the Bio-Medical Engineer from 9:45 a.m. to 12:45 p.m., the second floor Sleep Center Hall stairway exit, the second floor Patient Hall stairway exit, and the second floor Obstetrics Hall stairway exit discharged into enclosed stairways to the first floor and exited into the parking lot. Furthermore, the three first floor exit stairways continued to the basement and lacked stairway interrupters at the first floor level of discharge. This was verified by the Bio-Medical Engineer at the time of observations.

2. Based on observation and interview, the facility failed to ensure 1 of 4 second floor exit accesses leading to the first floor discharge path with stairs was provided with a handrail. LSC 7.2.2.4.2 requires stairs and ramps shall have handrails on both sides. In addition, handrails shall be provided within 30 inches of all portions of the required egress width of stairs. The required egress width shall be provided along the natural path. Exception No 3: Existing stairs, existing ramps, stairs within dwelling units and within guest rooms, and ramps within dwelling units and guest rooms shall be permitted to have a handrail on one side only. This deficient practice could affect any patients using the second floor Obstetrics Hall East stairway exit enclosure during an evacuation.

Findings include:

Based on observation on 03/17/14 at 12:15 p.m. with the Bio-Medical Engineer, the second floor Obstetrics Hall East stairway discharged to the first floor East Wing exit onto an asphalt sidewalk. Furthermore, the sidewalk surface extended fifteen feet to two stairs and up to a twelve foot landing with one stair on the opposite side of the landing and onto the parking lot. The stairs on both sides of the landing lacked a handrail. The lack of handrail on each side of the fifteen foot sidewalk landing was verified by the Bio-Medical Engineer at the time of observation.

1. Based on observation and interview, the facility failed to replace 1 of over 300 second floor sprinklers covered in brown corrosion. LSC 9.7.5 requires all automatic sprinkler systems shall be inspected, tested and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 1998 edition, 2-2.1.1 requires any sprinkler shall be replaced which is painted, corroded, damaged, loaded, or in the improper orientation. This deficient practice could affect any patient on the Sleep Center Hall.

Findings include:

Based on observation on 03/17/14 at 11:55 a.m. with the Bio-Medical Engineer, the Sleep Center Hall staff office closet sprinkler was completely covered in brown corrosion. This was verified by the Bio-Medical Engineer at the time of observation.


33713

2. Based on record review and interview, the facility failed to ensure 1 of 1 automatic dry sprinkler piping systems was inspected every five years as required by NFPA 25, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems 10-2.2. Section 10-2.2, Obstruction Prevention, states systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This deficient practice affects all occupants.

Findings include:

Based on record review with the Bio-Mechanical Engineer on 03/17/14 at 10:15 a.m., the Shambaugh & Son's sprinkler inspection report titled "Sprinkler Inspection Certificate" dated 02/19/14 provided a check mark in a "yes" box that an internal pipe inspection had been done. The sprinkler inspection documentation did not indicate when the most recent internal inspection of the dry sprinkler system had been done. Based on an interview with the Bio-Mechanical Engineer at the time of record review, 2009 was thought to be when the internal inspection of the dry sprinkler system had been done but specific documentation of the internal pipe inspection was not available for review.

1. Based on observation, record review, and interview; the facility failed to enforce the policy for the use of portable space heaters in the facility in accordance with NFPA 101, Section 19.7.8. This deficient practice could affect at any patient, staff or visitor throughout the hospital.

Findings include:

Based on a review of the hospital's written portable space heater policy on 03/17/14 at 9:30 a.m. with the Facilities Director, the written policy stated portable electric space heaters may be used in staff offices under supervision by facility staff, turned off when not in use, and hospital maintenance staff must approve each space heating device to ensure the heating elements do not exceed 212 degrees Fahrenheit. Based on an interview with the Facilities Director on 03/17/14 at 9:35 a.m., there was no written evidence to indicate the heating elements of the electric portable space heaters in use did not exceed 212 degrees Fahrenheit. Based on observations on 03/17/14 during a tour from 10:45 a.m. to 12:45 p.m. and then from 1:15 p.m. to 2:45 p.m., the following was noted:
a. At least three electric space heaters were observed in use in the Emergency Department (ED) at two workstations and the nurses station which were part of a patient care area.
b. An electric space heater was observed in use in the Recertification office which was open to a patient/visitor waiting area. Based on interview with the Facilities Director at the exit conference at 3:00 p.m. on 03/17/14, the facility has purchased and distributed at least sixty electric space heaters throughout the hospital and the facility does not have documentation that the heating elements of the space heaters will not exceed 212 degrees Fahrenheit.


10595

2. Based on observation, interview, and record review; the facility failed to ensure evidence was provided for portable space heating devices used in nonsleeping staff and employee areas to ensure the heating elements of the devices do not exceed 212 degrees Fahrenheit. This deficient practice could affect all patients on the second floor in the event a staff used portable space heater started fire.

Findings include:

Based on a review of the hospital's written portable space heater policy on 03/17/14 at 9:30 a.m. with the Facilities Director, the written policy stated portable electric space heaters may be used in staff offices under supervision by facility staff, turned off when not in use, and hospital maintenance staff must approve each space heating device to ensure the heating elements do not exceed 212 degrees Fahrenheit. Based on an interview with the Facilities Director on 03/17/14 at 9:35 a.m., there was no written evidence to indicate the heating elements of the electric portable space heaters in use did not exceed 212 degrees Fahrenheit. Based on observations on 03/17/14 during a tour of the second floor with the Bio-Medical Engineer from 9:45 a.m. to 12:45 p.m., the sleep center staff office, the rehabilitation gym director office, and the director services office each had a portable electric space heater in use. Based on observation of the three space heaters, there was no written information on each space heater to indicate the maximum temperature of the heating elements. The lack of written evidence the portable space heaters' heating elements did not exceed 212 degrees Fahrenheit was verified by the Bio-Medical Engineer at the time of observations.

Based on observation and interview, the facility failed to ensure the means of egress was continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency for 2 of 4 exits. This deficient practice could affect staff and visitors throughout the ground floor of the hospital.

Findings include:

Based on observation with the Facilities Director during a tour of the facility on 03/17/14 from 10:45 a.m. to 12:45 p.m. and then from 1:15 p.m. to 2:45 p.m., the following was noted:
a. The ground floor north exit stairwell had storage of a salad bar, four coolers and assorted dietary equipment obstructing the exit.
b. The dietary corridor leading to the ground floor north exit had storage of a desk, chairs, file cabinets and carts obstructing the means of egress.
c. The ground floor south exit stairwell had storage of a paint cart, paint cans, a ladder and sawhorses obstructing the exit.
Based on interview at the times of observation, the Facilities Director acknowledged the aforementioned conditions.

Based on observation, interview and record review; the facility failed to ensure the care and maintenance of 1 of 1 rolling fire doors was in accordance with NFPA 80. LSC 4.5.7 requires any device, equipment or system which is required for compliance with the provisions of this Code, such device, equipment or system shall thereafter be maintained unless the Code exempts such maintenance. NFPA 80, 1999 Edition, the Standard for Fire Doors and Fire Windows, Section 15-2.4.3 requires all horizontal or vertical sliding and rolling fire doors to be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction. This deficient practice could affect any staff or visitor using the ground floor dining room adjacent to the kitchen.

Findings include:

Based on observation on 03/17/14 during the tour from 10:45 a.m. to 12:45 p.m. with the Facilities Director, there was a rolling fire door protecting the opening from the kitchen to the main dining room without an attached inspection tag. Based on interview during paperwork review from 9:45 a.m. to 12:45 p.m. with the Facilities Director, the Facilities Director acknowledged there was no documentation of an annual inspection or test since installation to check for proper operation and full closure of the vertical rolling fire door.

Based on observation and interview, the facility failed to ensure high current draw electrical devices were not plugged into power strips as a substitute for fixed wiring. LSC 19.5.1 requires utilities to comply with Section 9.1. LSC 9.1.1 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 1999 Edition. NFPA 70, Article 400-8 requires, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could affect staff and visitors.

Findings include:

Based on observation with the Facilities Director during a tour of the facility on 03/17/14 from 1:15 p.m. to 2:45 p.m., the following was noted:
a. The Cardiopulmonary office had a microwave plugged into a power strip.
b. The Business office had a refrigerator plugged into a power strip..
c. The Recertification office had a refrigerator plugged into a power strip.
Based on interview at the times of observation, the Facilities Director acknowledged the aforementioned conditions.

Based on record review and interview, the facility failed to provide a complete written policy indicating procedures to be followed in the event the automatic sprinkler system has to be placed out of service for 4 hours or more in a 24 hour period in accordance with LSC, Section 9.7.6.1. in order to protect 14 of 14 patients. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, 1998 Edition, Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 11-5(d) requires the local fire department be notified of a sprinkler impairment and 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified. This deficient practice could affect all occupants.

Findings include:

Based on review of the facility's fire watch policy and procedure on 03/17/14 during paperwork review from 9:45 a.m. to 12:45 p.m. with the Facilities Director, the fire watch procedure for an out of service sprinkler system was not complete. The policy and procedure did not include notification to the Indiana State Department of Health which is an authority having jurisdiction. Based on interview at the time of record review, the Facilities Director acknowledged the fire watch policy and procedure did not include notification to the Indiana State Department of Health.

Based on record review and interview, the facility failed to ensure its written fire watch policy addressed all procedures to be followed in this facility in the event the fire alarm system has to be placed out of service for 4 hours or more in a 24 hour period in accordance with LSC, Section 9.6.1.8. in order to protect 14 of 14 patients. This deficient practice could affect all occupants of the facility.

Findings include:

Based on review of the facility's fire watch policy and procedure on 03/17/14 during paperwork review from 9:45 a.m. to 12:45 p.m. with the Facilities Director, the fire watch procedure for an out of service fire alarm system was not complete. The policy and procedure did not include notification to the Indiana State Department of Health which is an authority having jurisdiction. Based on interview at the time of record review, the Facilities Director acknowledged the fire watch policy and procedure did not include notification to the Indiana State Department of Health.