HospitalInspections.org

Based on document review and interview, the governing board failed to assess, via the facility's quality assessment and performance improvement (QAPI) program, two (2) services (medical records and nursing) provided under contract.

Findings:

1. Review of the facility's QAPI program indicated it did not include a monitor, standard and review by the governing board, for the contracted services of medical records and nursing.

2. In interview, on 3-21-13 at 3:30 pm, employee #A1 confirmed the above. No other documentation was provided prior to exit.

Based on document review and interview, the governing board failed to review directly or as part of its review of the facility's quality assurance and performance improvement program, two (2) contracted services (medical records and nursing) in order to assure the services were provided in a safe and effective manner.

Findings:

1. Review of the governing board meeting minutes for calendar year 2012 indicated the contracted services of medical records and nursing were not included as part of any direct review by the governing board or as part of the governing board's review of the facility's quality assurance and performance improvement program.

2. In interview, on 3-21-13 at 3:30 pm, employee #A1 confirmed the above. No other documentation was provided prior to exit.

Based on document review and interview, the facility failed to include a monitor and standard for 2 services (medical records and nursing) furnished by a contractor in its quality assessment and performance improvement (QAPI) program.

Findings:

1. Review of the facility's QAPI program indicated it did not include a monitor and standard for the contracted services of medical records and nursing.

2. In interview, on 3-21-13 at 3:30 pm, employee #A1 confirmed the above. No other documentation was provided prior to exit.

Based on document review and interview, the facility failed to follow its procedure for processing medical staff applications for reappointment for 3 of 11 (MD#1, MD#2 and MD#10) physician credential files reviewed.

Findings:

1. Review of the Governing Board Bylaws, approved 10-23-12, indicated in a section entitled PROCEDURE FOR PROCESSING APPLICATIONS FOR STAFF REAPPOINTMENT:

The Medical Staff Coordinator will request, on each reapplicant, a Credentialing
Performance Profile ... .

In the event a Medical Staff member has limited ... or no activity at Johnson Memorial
Hospital, an "Evaluation for Reappointment" form will be sent to all hospitals where the
applicant has indicated he/she holds clinical privileges and medical staff membership.

If the Medical Staff member has no other hospital affiliations or no activity at another
facility, the medical Staff Coordinator will notify the practitioner that he/she is required to
allow an audit of his/her office practice charts by a professional peer.

2. Credential files of MD#1, reappointment date February 2013, MD#2, reappointment date December 2012 and MD#10, reappointment date January 2013 lacked documentation of performance review using any of the processes described above as part of the credentialing process.

3. In interview, on 3-19-13 at 1:05 pm, employee #A6 confirmed the above.

4. In interview, on 3-19-13 at 1:05 pm, employee #A6 indicated the above-stated physicians had limited or no activity and that he had not sent the "Evaluation for Reappointment" form to all hospitals where the applicants MD#1, MD#2 and MD#10 had indicated they hold clinical privileges and medical staff membership. No further documentation was provided prior to exit.

Based on observation, document review and interview, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for 1 of 1 open intensive care unit (ICU) medical record (MR) (Patient #6).

Findings include:

1. During the facility tour of the ICU on 0319-13 at 1405 hours, patient #6 was observed to be on a ventilator.

2. Review of patient #6's MR indicated the following Physician Orders on 03-18-13 at 1740 hours:
Richmond Agitation-Sedation Scale (RASS) RASS Target -2 -3.
The nursing assessment by a Registered Nurse (RN) on 03-18-13 at 1900 hours indicated the patient was at -4 RASS.
The nursing assessment by a RN on 03-18-13 at 2100 hours indicated the patient was at -4 RASS.
The nursing assessment by a RN on 03-18-13 at 2300 hours indicated the patient was at -5 RASS.
The nursing assessment by a RN on 03-19-13 at 0100 hours indicated the patient was at -5 RASS.
The nursing assessment by a RN on 03-19-13 at 0300 hours indicated the patient was at -5 RASS.
The nursing assessment by a RN on 03-19-13 at 0500 hours indicated the patient was at -5 RASS.
The MR lacked documentation that interventions were implemented to get the patient to a RASS -2 -3 level.

3. On 03-19-13 at 1435 hours, staff #40 & 50 confirmed the RASS documentation on patient #6.

Based on observation and interview, the facility failed to ensure the privacy of medical records in 1 instance in which unauthorized individuals could gain access to confidential patient information.

Findings:

1. On 3-18-13 at 1:10 pm in the presence of employee #A7, it was observed in an alcove in the Radiology area, there were 3 barrels of exposed radiological film containing patient identifiers. The area was secured only with a draw curtain which did not lock. It was also observed the alcove area could not be observed at all times by department personnel to ensure only authorized individuals had access to the alcove.

Based on observation and interview, the facility failed to ensure a policy and procedure to indicate which authorized personnel have access to locked medication storage areas in 2 instances.

Findings:

1. On 3-18-13 at 1:50 pm in the presence of employee #A7, it was observed in the Mammography area there were medications in a locked cabinet.

2. In interview on the above date and time, staff indicated techs (non-RN or LPN) had access to the locked medications. Staff was requested to provide documentation of a policy and procedure to indicate which authorized personnel have access to a locked medication storage areas. No documentation was provided prior to exit.

3. On 3-18-13 at 2:30 pm in the presence of employee #A7, it was observed in the Wound Care Center there were medications in a locked cabinet.

4. In interview on 3-18-13 at 2:30 pm, staff indicated non-RN or LPN personnel had access to the locked medications. Staff was requested to provide documentation of a policy and procedure to indicate which authorized personnel have access to a locked medication storage areas. No documentation was provided prior to exit.

Based on Life Safety Code (LSC) survey, Johnson Memorial Hospital was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2000 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.

Johnson Memorial Hospital is comprised of the main hospital in Franklin, IN (Building 01) with the attached new surgery center (Building 04), Johnson Memorial Immediate Care in Franklin, IN (Building 02), and Stones Crossing in Greenwood, IN (Building 03).

Johnson Memorial Hospital's main building, Building 01, a three story partially sprinklered building of Type II (111) construction with a monitored fire alarm system with smoke detection in the corridors and in all areas open to the corridors was surveyed with Chapter 19, Existing Health Care Occupancies. Building 01 provides overnight care. Building 01 has a capacity of 125 and had a census of 44 at the time of this survey.

The new surgery center for Johnson Memorial Hospital in Franklin, IN (Building 04), a two story partially sprinklered building of Type II (222) construction with a monitored fire alarm system with smoke detection in the corridors and in all areas open to the corridor was surveyed with Chapter 18, New Health Care Occupancies. Building 04 provides surgical services.

Johnson Memorial Immediate Care in Franklin, IN (Building 02), a split level one story fully sprinklered building of Type V (000) construction with a monitored fire alarm system with smoke detection in the corridors and in all areas open to the corridor was surveyed with Chapter 39, Existing Business Occupancies. Building 02 provides outpatient clinic and rehabilitative services during regular business hours.

Stones Crossing in Greenwood, IN (Building 03), a one story nonsprinklered building of Type V (000) construction without a fire alarm system was surveyed with Chapter 39, Existing Business Occupancies. Building 03 provides lab and radiology services during regular business hours.

Based on LSC survey and deficiencies found (see CMS 2567L), it was determined that the facility failed to ensure a complete automatic sprinkler system was provided for 4 of 5 elevator equipment rooms, 1 of 5 stairwells, 1 of 1 cloth canopies and 1 of 1 high voltage rooms (see K 012 and 056), failed to ensure 4 of 4 open use areas were separated from the corridor, or met an Exception (see K 017), failed to ensure 1 of 20 corridor doors in the Maternity Center were provided with a means suitable for keeping the door closed (see K 018), failed to ensure 1 of 8 fire rated stairway doors on the first floor closed and latched into the door frame (see K 020), failed to ensure 1 of 5 doors serving smoke barrier walls were held open only by a device arranged to automatically close the door or close the door upon activation of the fire alarm system (see K 021), failed to ensure 14 of 14 openings through smoke barriers were protected to maintain the smoke resistance of each smoke barrier (see K 025), failed to ensure 5 of 5 corridor doors to hazardous areas such as a combustible storage room over 50 square feet in size or a soiled linen room were provided with a self closing device which would cause the door to automatically close and latch into the door frame (see K 029), failed to maintain the vertical opening protection of 2 of 8 exit stairs (see K 033), failed to ensure 1 of 2 first floor fire door sets was arranged to automatically close and latch (see K 044), failed to document testing of emergency lighting for 4 of 4 battery operated emergency lights in the surgery rooms (see K 046), failed to document fire drills conducted on the first and second shift for 2 of 4 quarters (see K 050), failed to ensure 3 of over 200 smoke detectors connected to the fire alarm system were properly separated from an air supply (see K 051), failed to ensure 2 of 5 Penthouse Electrical Equipment rooms were provided with manual fire alarm boxes which were unobstructed and readily accessible (see K 052), failed to ensure 1 of 1 automatic sprinkler systems was inspected every five years (see K 062), failed to ensure the pressure gauge reading for 1 of 31 portable ABC class fire extinguishers on second floor was in the acceptable range (see K 064), failed to regulate the use of 1 of 1 portable space heaters in staff offices (see K 070), failed to ensure 3 of 3 Day Care Center hanging curtains were flame retardant (see K 074), failed to ensure a monthly load test for 2 of 2 emergency generators (see K 144), failed to ensure 4 of 20 electrical junction boxes in the Elevator equipment room # 4 on Penthouse level and 1 of 3 electrical junction boxes observed at the east pantry smoke wall on third floor containing electrical wiring were contained in junction boxes with covers (see K 147), failed to provide a complete written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period (see K 154) and failed to provide a complete written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period (see K 155) for Building 01, failed to ensure automatic sprinkler system components were inspected quarterly for 4 of 4 calendar quarters for Building 02 and failed to provide a one hour enclosure for 3 of 3 hazardous area storage rooms for Building 03 (see K 130), failed to ensure a complete automatic sprinkler system was provided for 1 of 1 elevator equipment rooms (see K 012), failed to ensure the passage of wire and/or pipe through 1 of 1 mechanical room smoke barriers was protected to maintain the smoke resistance of the smoke barrier (see K 025), failed to ensure 4 of 4 pairs of cross corridor doors in the Outpatient Suite were constructed to resist the passage of smoke (see K 027), failed to document testing of emergency lighting for 2 of 2 battery operated emergency lights in surgery rooms (see K 046), failed to document fire drills conducted on the first and second shift for 1 of 4 quarters (see K 050), failed to ensure 3 of 6 smoke detectors in the new surgery waiting area were installed where air flow would not adversely affect its operation (see K 051), failed to ensure a complete automatic sprinkler system was provided for 1 of 1 elevator equipment rooms (see K 056), failed to ensure a monthly load test for 2 of 2 emergency generators (see K 144), failed to provide a complete written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period (see K 154) and failed to provide a complete written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period (see K 155) for Building 04.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on observation, staff interview and document review, the facility failed to ensure a complete automatic sprinkler system was provided for 4 of 5 elevator equipment rooms, 1 of 5 stairwells, 1 of 1 cloth canopies and 1 of 1 high voltage rooms, failed to ensure 4 of 4 open use areas were separated from the corridor, or met an Exception, failed to ensure 1 of 20 corridor doors in the Maternity Center were provided with a means suitable for keeping the door closed, failed to ensure 1 of 8 fire rated stairway doors on the first floor closed and latched into the door frame, failed to ensure 1 of 5 doors serving smoke barrier walls were held open only by a device arranged to automatically close the door or close the door upon activation of the fire alarm system, failed to ensure 14 of 14 openings through smoke barriers were protected to maintain the smoke resistance of each smoke barrier, failed to ensure 5 of 5 corridor doors to hazardous areas such as a combustible storage room over 50 square feet in size or a soiled linen room were provided with a self closing device which would cause the door to automatically close and latch into the door frame, failed to maintain the vertical opening protection of 2 of 8 exit stairs, failed to ensure 1 of 2 first floor fire door sets was arranged to automatically close and latch, failed to document testing of emergency lighting for 4 of 4 battery operated emergency lights in the surgery rooms, failed to document fire drills conducted on the first and second shift for 2 of 4 quarters, failed to ensure 3 of over 200 smoke detectors connected to the fire alarm system were properly separated from an air supply, failed to ensure 2 of 5 Penthouse Electrical Equipment rooms were provided with manual fire alarm boxes which were unobstructed and readily accessible, failed to ensure 1 of 1 automatic sprinkler systems was inspected every five years, failed to ensure the pressure gauge reading for 1 of 31 portable ABC class fire extinguishers on second floor was in the acceptable range, failed to regulate the use of 1 of 1 portable space heaters in staff offices, failed to ensure 3 of 3 Day Care Center hanging curtains were flame retardant, failed to ensure a monthly load test for 2 of 2 emergency generators, failed to ensure 4 of 20 electrical junction boxes in the Elevator equipment room # 4 on Penthouse level and 1 of 3 electrical junction boxes observed at the east pantry smoke wall on third floor containing electrical wiring were contained in junction boxes with covers, failed to provide a complete written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period and failed to provide a complete written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period for Building 01, failed to ensure automatic sprinkler system components were inspected quarterly for 4 of 4 calendar quarters for Building 02 and failed to provide a one hour enclosure for 3 of 3 hazardous area storage rooms for Building 03, failed to ensure a complete automatic sprinkler system was provided for 1 of 1 elevator equipment rooms, failed to ensure the passage of wire and/or pipe through 1 of 1 mechanical room smoke barriers was protected to maintain the smoke resistance of the smoke barrier, failed to ensure 4 of 4 pairs of cross corridor doors in the Outpatient Suite were constructed to resist the passage of smoke, failed to document testing of emergency lighting for 2 of 2 battery operated emergency lights in surgery rooms, failed to document fire drills conducted on the first and second shift for 1 of 4 quarters, failed to ensure 3 of 6 smoke detectors in the new surgery waiting area were installed where air flow would not adversely affect its operation, failed to ensure a complete automatic sprinkler system was provided for 1 of 1 elevator equipment rooms, failed to ensure a monthly load test for 2 of 2 emergency generators, failed to provide a complete written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period and failed to provide a complete written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period for Building 04.

Findings include:

1. It was observed on 03/18/13 during the tour with POA1 between 11:00 a.m. and 4:00 p.m., the following areas lacked sprinkler coverage:
a. The Elevator equipment room # 4, Penthouse level, lacked sprinkler coverage for an area of 35 feet by 30 feet on the south end of the room.
b. Stairwell # 3 leading up to the Elevator equipment room # 4 was not sprinklered.
c. The Elevator equipment room # 25, Penthouse level,was not sprinklered.
d. The Elevator equipment room # 1, Penthouse level, was not sprinklered.
e. The Elevator equipment room # 2, Penthouse level, was not sprinklered.
f. The sixty foot long cloth canopy outside the Outpatient exit on first floor which had an aluminum frame and no documentation of the flame spread rating for the cloth canopy was not sprinklered.
e. The High voltage room # 22 on radiology hall first floor was not sprinklered.

2. In interview on 03/18/13 at the time of the observations, it was acknowledged by POA1 that the aforementioned rooms lacked sprinkler coverage.

3. It was observed on 03/18/13 during the tour with POS1 from 1:15 p.m. to 2:45 p.m., the first floor canteen was open to the corridors.

4. In interview at the time of observation, POS1 acknowledged the first floor canteen was not separated from the corridor and lacked smoke detector protection in the canteen and the corridor adjacent to the canteen.

5. It was observed on 03/18/13 during the tour from 2:27 p.m. to 2:52 p.m. with POA1, the first floor wheelchair storage room and the two third floor Pantry rooms were open to the corridors.

6. In interview on 03/18/13 at the time of the observations, POA1 acknowledged the first floor wheelchair storage room and the third floor Pantries located on the east and west sides of Center hall were not separated from the corridor and lacked smoke detector protection in each room.

7. It was observed on 03/18/13 during the tour with POS1 from 10:15 a.m. to 12:15 p.m. on the second floor of the hospital, the C-section surgery room door in the Maternity Center was not provided with a latching mechanism.

8. In interview at the time of observation, POS1 acknowledged the C-section room door was not provided with a latching mechanism.

9. It was observed on 03/18/13 during the tour with POS1 from 10:15 a.m. to 12:15 p.m. on the second floor of the hospital, pencil size holes through the corridor door above the latch were noted in the Maternity Center Doctor's sleeping room, the Information Systems Office (606), and patient rooms 284 and 285.

10. In interview at the time of observation, POS1 acknowledged the above mentioned room doors had holes through the doors and were not smoke resistant.

11. It was observed on 03/18/13 during the tour with POS1 from 1:15 p.m. to 2:45 p.m. on the first floor of the hospital, the Outpatient Coding office was provided with a kick down door stop attached to the bottom of the door.

12. In interview at the time of observation, POS1 acknowledged the Outpatient Coding office was provided with a kick down door stop.

13. It was observed on 03/19/13 with POS1 during the tour from 10:30 a.m. to 11:15 a.m. on the first floor of the hospital, the corridor door to Stairwell # 6 failed to latch into the door frame which left a one inch gap between the door and the door frame.

14. In interview at the time of observation, POS1 acknowledged the corridor door to Stairwell # 6 failed to latch into the door frame which left a one inch gap between the door and the door frame.

15. It was observed on 03/18/13 at 11:45 a.m. with POA1, the smoke door next to elevator # 1 on the third floor was held open by a flip down doorstop which would not allow the door to close automatically upon activation of the fire alarm system.

16. In interview on 03/18/13 at 11:47 a.m., it was acknowledged by POA1, the aforementioned smoke door was propped open with a flip down doorstop.

17. It was observed on 03/18/13 during the tour with POS1 from 10:15 a.m. to 12:15 p.m. on the second floor of the hospital:
a. The smoke barrier above the ceiling tile near the Pharmacy had two, one inch diameter holes where cable and conduit were going through a penetrating sleeve which was not firestopped.
b. The smoke barrier above the ceiling tile near the Nursing Center had two, one inch diameter holes where cable and conduit were going through a penetrating sleeve which was not firestopped.

18. It was observed on 03/18/13 during the tour with POS1 from 1:15 p.m. to 2:45 p.m. on the first floor of the hospital, Equipment Room 14, identified on the Level 1 Fire & Smoke Separation Diagram supplied by the facility as having a one hour rated separation had eight cable penetrations which were not firestopped.

19. It was observed on 03/19/13 during the tour with POS1 from 10:30 a.m. to 11:15 a.m. on the first floor of the hospital, the smoke barrier wall above the ceiling in the corridor above Door 504 had two rectangular cut outs in the smoke barrier wall through through which two cables passed. Each of the two openings were not fire stopped. One rectangular opening measured four inches by six inches and the second rectangular opening measured two inches by five inches.

20. In interview at the time of the observations, POS1 acknowledged the aforementioned smoke barrier penetrations were not fire stopped.

21. It was observed on 03/18/13 during the tour with POS1 from 10:15 a.m. to 12:15 p.m. on the second floor of the hospital:
a. The Pharmacy store room door lacked a self closing device, contained a large number of cardboard boxes stored on shelves, and measured over 60 square feet in size.
b. The door to the CCU/PCU soiled utility room used for storage of soiled linen was provided with a door closer, but the door struck the frame and did not self close and latch.

22. It was observed on 03/18/13 during the tour with POS1 from 1:15 p.m. to 2:45 p.m. on the first floor of the hospital:
a. The door to File Room A-Medical Records lacked a self closing device. The room contained a large number of paper files stored on open shelves and measured over 100 square feet.
b. The door to File Room B-Medical Records lacked a self closing device. The room contained a large number of paper files stored on open shelves and measured over 100 square feet.

23. In interview at the time of observations, the lack of functioning door closing devices was acknowledged by POS1.

24. It was observed on 03/18/13 at 11:50 a.m. with POA1, the Education # 5 Storage room on the third floor of the hospital contained thirty-six cardboard boxes, was over fifty square feet in area and lacked a self closing device on the corridor door.

25. In interview at the time of the observation, POA1 acknowledged no closing device was present on the door to the Education # 5 Storage room.

26. It was observed during the tour from 10:15 a.m. to 12:15 p.m. and from 1:15 p.m. to 2:45 p.m. on 03/18/13 with POS1:
a. the label on the door indicating a fire resistance rating was missing from the second floor stairwell # 4 door.
b. the label on the door indicating a fire resistance rating was painted over on the second floor stairwell # 7 door.
c. the label on the door indicating a fire resistance rating was missing from the second floor stairwell # 4 door.

27. In interview at the time observations, POS1 acknowledged the stairwell doors had painted or missing fire door labels.

28. It was observed on 03/18/13 with POS1 during the tour from 1:15 p.m. to 2:45 p.m. on the first floor of the hospital, the fire door set at the Building 1101 connector near room G110 was tested two times with POS1. The fire door set which was rated for 90 minutes failed to latch each time the doors were released to close, leaving a one inch gap.

29. In interview at the time of observation, POS1 acknowledged the aforementioned fire doors did not close and latch.

30. It was observed with POS1 during a tour of the facility from 10:30 a.m. to 11:15 a.m. on 03/19/13, battery operated lighting systems in each of the four surgery rooms.

31. Review of "Johnson Memorial Hospital - Plant Operations Department: Lighting Emergency" documentation with FM1 from 9:40 a.m. to 12:15 p.m. on 03/18/13 indicated functional testing of four battery operated emergency lights in four surgery rooms was not itemized for monthly tests conducted on 09/09/12, 10/24/12, 11/07/12 and 01/29/13.

32. In interview at the time of record review, FM1 acknowledged monthly functional testing documentation for four battery operated emergency lights in four surgery rooms was not itemized for the aforementioned monthly tests.

33. Review of "Code Red Fire Drill Critique" and "Fire Alarm Report" documentation with FM1 from 9:40 a.m. to 12:15 p.m. on 03/18/13 indicated documentation of a fire drill conducted on the first and second shift for the third quarter of 2012 and on the second shift for the first quarter of 2012 was not available for review. Third shift fire drills conducted on 03/27/12, 03/29/12, 06/28/12 and 11/29/12 were conducted, respectively, at 11:29 p.m., 12:05 a.m., 11:50 p.m. and 12:00 p.m.

34. In interview at the time of record review, FM1 acknowledged fire drill documentation on the aforementioned shifts was not available for review and third shift fire drills were not conducted at unexpected times under varying conditions.

35. It was observed on 03/18/13 with POS1 during the tour from 10:15 a.m. to 12:15 p.m. on the second floor of the hospital, smoke detectors identified as 6-06, 6-015 and 6-16 located in patient rooms in the Maternity Center were 12 inches from the air supply in the patient room.

36. In interview at the time of observation, POS1 acknowledged the aforementioned smoke detectors were less than three feet from an air supply vent and agreed the air flow could interfere with smoke detector function.

37. It was observed on 03/18/13 between 09:45 a.m. and 11:00 a.m. with POA1, the # 1 and # 2 Penthouse Electrical Equipment rooms lacked manual fire alarm boxes for each emergency exit out of the rooms.

38. In interview at the time of the observations, POA1 acknowledged the aforementioned Penthouse Electrical Equipment rooms lacked a manual fire alarm box at each exit.

39. It was observed with POA1 on 03/18/13 during the tour between 11:00 a.m. and 4:00 p.m., the following areas lacked sprinkler coverage:
a. Elevator equipment room # 4, Penthouse level, lacked sprinkler coverage for an area of 35 feet by 30 feet on the south end of the room.
b. Stairwell # 3 leading up to the Elevator equipment room # 4 was unsprinklered.
c. Elevator equipment room # 25, Penthouse level,was not sprinklered.
d. Elevator equipment room # 1, Penthouse level, was not sprinklered.
e. Elevator equipment room # 2, Penthouse level, was not sprinklered.
f. The sixty foot long cloth canopy outside the Outpatient exit on first floor with an aluminum frame and no documentation of the flame spread rating for the cloth canopy was not sprinklered.
e. High voltage room # 22 on radiology hall first floor was not sprinklered.

40. In interview on 03/18/13 at the time of the observations, it was acknowledged by POA that the aforementioned rooms lacked sprinkler coverage.

41. Record review with FM1 from 9:40 a.m. to 12:15 p.m. on 03/18/13 indicated documentation of an internal pipe inspection for the automatic sprinkler system was not available for review.

42. In interview at the time of record review, FM1 stated the automatic sprinkler system was initially installed in 1983 and acknowledged documentation of an internal pipe inspection was not available for review.

43. It was observed on 03/18/13 with POS1 during the tour from 1:15 p.m. to 2:45 p.m. on the first floor of the hospital, one of three automatic sidewall sprinklers in the Day Care Center "Chimp" room had paint on the deflector and fusible link.

44. In interview at the time of observation, POS1 acknowledged the paint on the sprinkler.

45. It was observed on 03/18/13 with POS1 during the tour from 1:15 p.m. to 2:45 p.m. on the first floor of the hospital, the sprinkler gauge on the inspector's test line located in Equipment Room # 5 had a manufacture date of 1985.

46. In interview at the time of observation, POS1 acknowledged the gauge was manufactured in 1985.

47. It was observed on 03/19/13 at 10:05 a.m. with POA1, two pressure gauges on the sprinkler riser system located in the Equipment room # 21 on first floor had manufacturer's dates of 1984 and 1981.

48. In interview on 03/19/13 at 3:20 p.m. with POS1, it was acknowledged the pressure gauges had exceeded the five year requirement for recalibration or replacement.

49. It was observed on 03/19/13 at 10:55 a.m. with POA1, the gauge on the ABC Class portable fire extinguisher # 354 on the second floor in the Main hall indicated the extinguisher was overcharged.

50. In interview on 03/19/13 at 10:56 a.m. with POA1, it was agreed the gauge reading was not in the normal operating range and he/she was unsure if it would affect the operation of the fire extinguisher.

51. It was observed on 03/19/13 at 10:55 a.m. with POA1, a portable space heater which was plugged in for use was located in the Administrator's office on Women's Care Group on first floor.

52. In interview on 03/19/13 at 10:59 a.m., POA1 acknowledged space heaters were not allowed.

53. It was observed on 03/18/13 with POS1 during the tour from 10:15 a.m. to 12:15 p.m. on the second floor of the hospital, a hanging curtain covering the Day Care Center food cart storage area and window curtains in the Day Care Center "Chimp" room lacked attached documentation stating they were inherently flame retardant.

54. In interview at the time of observation with POS1, there was no documentation regarding flame retardancy for these curtains available for review.

55. Review of "Johnson Memorial Hospital - Plant Operations Department: Generators" documentation with FM1 from 9:40 a.m. to 12:15 p.m. on 03/18/13 indicated monthly load test documentation for the period 3/01/12 through 02/01/13 for each of the two emergency generators identified as 021780 and 002399 did not indicate if the generator ran under operating temperature conditions, at not less than 30% of the EPS nameplate rating, or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.

56. In interview at the time of record review, FM1 acknowledged monthly load test documentation did not indicate each of the two generators ran under operating temperature conditions, at not less than 30% of the EPS nameplate rating, or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.

57. It was observed on 03/18/13 during the tour between 9:50 a.m. to 2:52 p.m. with POA1, the following electrical junction boxes with electrical wires jutting out of them were without a cover:
a. The electrical junction box on the east middle end of the Equipment room # 4, Penthouse level, had four electrical wire in a electrical junction box without a cover.
b. The electrical junction box above the pull station on the Equipment room # 4, Penthouse level, had three electrical wires in a junction box without a cover.
c. The two electrical junction boxes on the east air handler units at the east end of Equipment room # 4, Penthouse level, had four electrical wires in each junction box without a cover.
d. The electrical junction box above the ceiling next to the east pantry smoke wall on third floor had nine electrical wires jutting out of the electrical box without a cover.

58. In interview on 03/18/13 at the time of the observations, POA1 acknowledged the aforementioned electrical junction boxes were not protected with a cover.

59. Review of "Johnson Memorial Hospital Safety Policy: Utility Failures" documentation with FM1 from 9:40 a.m. to 12:15 p.m. on 03/18/13 indicated the emergency procedures for utility failures which includes the sprinkler system stated "Institute fire watch, minimize fire hazards, use phones and paging systems or runners to report fire" in response sprinkler alarms failure. The aforementioned fire watch policy did not include the following statements:
a. the building shall be evacuated or a fire watch shall be instituted in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period.
b. an impairment coordinator shall be assigned to conduct the fire watch and shall have no other duties.
c. the fire watch policy did not include notification of the Indiana State Department of Health, which is the authority having jurisdiction, the building owner and the building insurance carrier.

60. In interview at the time of record review, FM1 stated no additional fire watch documentation was available for review and acknowledged the written fire watch policy did not include the aforementioned statements.

61. Review of "Johnson Memorial Hospital Safety Policy: Utility Failures" documentation with FM1 from 9:40 a.m. to 12:15 p.m. on 03/18/13 indicated the emergency procedures for utility failures which includes the fire alarm system stated "Institute fire watch, minimize fire hazards, use phones and paging systems or runners to report fire" in response fire alarms failure. The aforementioned fire watch policy did not include the following statements:
a. the building shall be evacuated or a fire watch shall be instituted in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period.
b. the fire watch policy did not include notification of the Indiana State Department of Health, which is the authority having jurisdiction.

62. In interview at the time of record review, FM1 stated no additional fire watch documentation was available for review and acknowledged the written fire watch policy did not include the aforementioned statements.

63. Review of "Johnson Memorial Hospital - Plant Operations Department: ICC Sprinkler System/Monthly" documentation with POS1 from 1:15 p.m. to 2:00 p.m. on 03/19/13 indicated documentation of quarterly sprinkler system water flow alarm inspection reports for 2012 was not available for review.

64. In interview at the time of record review, POD1 stated the facility documents monthly checks of sprinkler system coverage but acknowledged documentation of quarterly inspections and tests of the sprinkler system and its components for 2012 was not available for review.

65. It was observed with POD1 during a tour of the facility from 2:00 p.m. to 3:10 p.m. on 03/19/13, the sprinkler system riser located in the mechanical room had three pressure gauges installed with the manufacture date of 1997 printed on each gauge.

66. In interview at the time of record review, POD1 stated no documentation of pressure gauge testing or replacement was available for review and acknowledged each of the three sprinkler system gauges had not been replaced or retested within the last 5 years.

67. It was observed with POD1 during a tour of the facility from 2:00 p.m. to 3:10 p.m. on 03/19/13, a spare sprinkler cabinet, spare sprinklers and sprinkler wrench were not provided for the automatic sprinkler system. Sidewall, standard upright and pendent sprinklers were observed installed in the facility.

68. In interview at the time of the observations, POD1 acknowledged a spare sprinkler cabinet, spare sprinklers and sprinkler wrench were not provided for the automatic sprinkler system.

69. Review of "Johnson Memorial Hospital-Plant Operations Department: Security System" documentation dated 08/01/12 and 11/01/12 with POD1 from 1:15 p.m. to 2:00 p.m. on 03/19/13 indicated documentation of an annual fire alarm system inspection was not available for review. The aforementioned documentation details procedures and the date of random tests of a single smoke detector and a single manual pull station to ensure fire alarm system activation, but there is no documentation of an annual test of all fire alarm system initiating devices and system components.

70. It was observed with POD1 during a tour of the facility from 2:00 p.m. to 3:15 p.m. on 03/19/13, seventeen smoke detectors were hard wired to the fire alarm system and four manual pull stations were observed in the facility.

71. In interview at the time of record review and of the observations, POD1 acknowledged documentation of annual testing of facility fire alarm initiating devices, alarm notification appliances, and batteries was not available for review.

72. Record review with POD1 from 1:15 p.m. to 2:00 p.m. on 03/19/13 indicated documentation of smoke detector sensitivity testing was not available for review.

73. It was observed with POD1 during a tour of the facility from 2:00 p.m. to 3:15 p.m., seventeen smoke detectors hard wired to the fire alarm system were observed in the facility.

74. In interview at the time of record review and of the observations, POD1 acknowledged documentation of smoke detector sensitivity testing in the last two years was not available for review.

75. It was observed with POD1 during a tour of the facility from 2:00 p.m. to 3:10 p.m. on 03/19/13, the smoke detector on the ceiling in the Occupational Therapy Gym near the south exit was located one foot from an air supply vent.

76. In interview at the time of observation, MD1 acknowledged the aforementioned smoke detector location was installed less than three feet from an air supply vent.

77. It was observed with POD1 during a tour of the facility from 2:00 p.m. to 3:10 p.m. on 03/19/13, there is only one phone line for the main fire alarm panel.

78. In interview at the time of observation, POD1 acknowledged there is only one phone line for the main fire panel.

79. It was observed with POD1 during a tour of the facility from 2:00 p.m. to 3:10 p.m. on 03/19/13, the portable fire extinguisher by the mechanical room next to the Occupational Therapy Gym waiting area had a label and collar affixed stating the most recent six year maintenance procedures were performed in September 2006.

80. In interview at the time of observation, POD1 acknowledged the most recent six year maintenance procedures for the portable fire extinguisher by the mechanical room next to the Occupational Therapy Gym waiting area was performed in September 2006.

81. Record review with POD1 from 1:15 p.m. to 2:00 p.m. on 03/19/13 indicated documentation of designated employee training in the use of portable fire extinguishers was not available for review.

82. It was observed with POD1 during a tour of the facility from 2:00 p.m. to 3:15 p.m. on 03/19/13, six portable fire extinguishers were in the facility.

83. In interview at the time of record review and of the observations, POD1 acknowledged documentation of designated employee training in the use of portable fire extinguishers in the facility was not available for review.

84. Review of "Johnson Memorial Hospital-Plant Operations Department: Exit Lights in Building" documentation with POD1 from 1:15 p.m. to 2:00 p.m. on 03/19/13 indicated documentation of an annual 90 minute test for facility battery operated lights was not available for review.

85. It was observed with POD1 during a tour of the facility from 2:00 p.m. to 3:15 p.m., sixteen battery operated emergency lights were observed in the facility.

86. In interview at the time of record review and of the observations, POD1 acknowledged documentation of an annual 90 minute test for facility battery operated lights was not available for review.

87. It was observed with POA1 during the tour from 1:15 p.m. to 2:45 p.m. on 03/19/13, the following rooms which were used to store patient files had exposed interior wood stud walls which did not provide one hour of fire resistance and were not sprinklered:
a. The west and south walls of the storage room on West Main hall had exposed wood stud walls.
b. The north and east walls of the storage room on East Main hall had exposed wood stud walls.
c. The north, east and west walls of the storage room on East Main hall had exposed wood stud walls.

88. In interview at the time of the observations, POA1 acknowledged the aforementioned storage areas had walls with exposed interior wood studs and were not sprinklered.

89. It was observed on 03/18/13 with POS1 during a tour of the new surgery center from 3:00 p.m. to 4:00 p.m., the new surgery elevator machine room lacked sprinkler coverage.

90. In interview at the time of observation, POS1 acknowledged the new surgery elevator machine room lacked sprinkler coverage.

91. It was observed on 03/18/13 with POS1 during a tour of the new surgery center from 3:00 p.m. to 4:00 p.m., there were two pipe sleeves with cables penetrating the labeled one hour fire rated walls of the new Surgery Mechanical room that were not firestopped. There were two intumescent firestop plugs lying on a wire shelf below the pipe sleeve penetrations.

92. In interview at the time of observation, POS1 acknowledged the pipe sleeves were not firestopped and did not know why the firestop plugs were not in place.

93. It was observed on 03/18/13 with POS1 during a tour of the new surgery center from 3:00 p.m. to 4:00 p.m., four sets of double doors each leading into the Outpatient Suite had a ½ inch gap between the set of doors when closed. Each set of double doors was not equipped with a rabbet, astragal or beveled at the meeting edges.

94. In interview at the time of observation, POS1 acknowledged the gap between the four sets of double doors would not resist the passage of smoke.

95. It was observed with POS1 during a tour of the facility from 10:30 a.m. to 11:15 a.m. on 03/19/13, battery operated lighting systems in each of the two new surgery rooms.

96. Review of "Johnson Memorial Hospital - Plant Operations Department: Lighting Emergency" documentation with FM1 from 9:40 a.m. to 12:15 p.m. on 03/18/13 indicated functional testing of two battery operated emergency lights in two surgery rooms was not available for review for October 2012 through February 2013.

97. In interview at the time of record review, FM1 stated the new surgery center commenced operation in October 2012 and acknowledged monthly functional testing documentation for two battery operated emergency lights in two surgery rooms for the aforementioned five month period was not available for review.

98. Review of "Code Red Fire Drill Critique" and "Fire Alarm Report" documentation with FM1 from 9:40 a.m. to 12:15 p.m. on 03/18/13 indicated documentation of a fire drill conducted on the first and second shift for the third quarter of 2012 was not available for review.

99. In interview at the time of record review, FM1 stated the new surgery center commenced operation in October 2012 and acknowledged fire drill documentation for the aforementioned third quarter shifts was not available for review.

100. It was observed on 03/18/13 with POS1 during a tour of the new surgery center from 3:00 p.m. to 4:00 p.m., three of the six smoke detectors in the surgery waiting area were located within one foot of an air supply duct.

101. In interview at the time of observation, this was acknowledged by POS1.

102. It was observed on 03/18/13 with POS1 during a tour of the new surgery center from 3:00 p.m. to 4:00 p.m., the new surgery elevator machine room lacked sprinkler coverage.

103. In interview at the time of observation, POS1 acknowledged the new surgery elevator machine room lacked sprinkler coverage.

104. Review of "Johnson Memorial Hospital - Plant Operations Department: Generators" documentation with FM1 from 9:40 a.m. to 12:15 p.m. on 03/18/13 indicated monthly load test documentation for the period 10/01/12 through 02/01/13 for each of the two emergency generators identified as 021780 and 002399 did not indicate the generator ran under operating temperature conditions, at not less than 30% of the EPS nameplate rating, or loading that maintains the minimum exhaust gas temperatures as recommended by the

Based on interview, the facility failed to have a policy whereby the the patient's physician may request a discharge plan.

Findings:

1. On 3-18-13 at 9:50 am, employee #A1 was requested to provide documentation of a hospital policy whereby the the patient's physician may request a discharge plan.

2. In interview, on 3-20-13 at 3:50 pm, employee #A11 indicated there was no such policy and no other documentation was provided prior to exit.