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Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 1 of 1 elevator equipment rooms in this two story building of Type II (222) construction which is required to be sprinklered. This deficient practice could affect six patients, staff and visitors in the new surgery center.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor 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. Based on interview at the time of observation, the Plant Operations Supervisor acknowledged the new surgery elevator machine room lacked sprinkler coverage.

Based on observation and interview, 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 in this three story building of Type II (111) which is required to be fully sprinklered. This deficient practice could affect ten patients, staff and visitors.

Findings include:

Based on observations with the Plant Operations Assistant on 03/18/13 during the tour 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.
Based on interview on 03/18/13 at the time of the observations, it was acknowledged by the Plant Operations Assistant the aforementioned rooms lacked sprinkler coverage.

Based on observation and interview, the facility failed to ensure 4 of 4 open use areas were separated from the corridor, or met an Exception. LSC 19.3.6.1, Exception # 1, Spaces shall be permitted to be unlimited in area and open to the corridor, provided the following criteria are met: (a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas. (b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the smoke compartment in which the space is located is protected throughout by quick response sprinklers. (c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space. (d) The space does not obstruct access to required exits. This deficient practice affects an unknown number of patients, staff and/or visitors.

Findings include:

a. Based on observation on 03/18/13 during the tour from 1:15 p.m. to 2:45 p.m. with the Plant Operations Supervisor, the first floor canteen was open to the corridors. Furthermore, Exception # 1, requirement (b) and (c) of the Life Safety Code, Chapter 19.3.6.1 was not met as follows: the open area and the corridor to which the canteen was open to in the same smoke compartment was not protected by an automatic smoke detection system or arranged to allow direct supervision by facility staff from a continuously staffed area such as a nurses' station. Based on interview at the time of observation, the Plant Operation Supervisor 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.
b. Based on observation on 03/18/13 during the tour from 2:27 p.m. to 2:52 p.m. with the Plant Operations Assistant, the first floor Wheelchair storage room and the two third floor Pantry rooms were open to the corridors. Furthermore, Exception # 1, requirement (b) and (c) of the Life Safety Code, Chapter 19.3.6.1 were not met as follows: the open area and the corridor to which the Wheelchair room and Pantry rooms were open to in the same smoke compartment were not protected by an automatic smoke detection system or arranged to allow direct supervision by facility staff from a continuously staffed area such as a nurses' station. Based on interview on 03/18/13 at the time of the observations, the Plant Operation Assistant 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.

1. Based on observation and interview, the facility failed to ensure 1 of 20 corridor doors in the Maternity Center were provided with a means suitable for keeping the door closed. This deficient practice could affect two patients, staff and visitors.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor during the tour 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. Based on interview at the time of observation, the Plant Operations Supervisor acknowledged the C-section room door was not provided with a latching mechanism.

2. Based on observation and interview, the facility failed to ensure 4 of 20 corridor doors in the Maternity Center would resist the passage of smoke. This deficient practice could affect two patients, staff and visitors.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor during the tour 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. Based on interview at the time of observation, the Plant Operations Supervisor acknowledged the above mentioned room doors had holes through the doors and were not smoke resistant.

3. Based on observation and interview, the facility failed to ensure 1 of 1 Outpatient Coding office doors protecting corridor openings did not have an impediment to the closing of the door. This deficient practice could affect two staff and visitors.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor during the tour 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. Based on interview at the time of observation, the Plant Operations Supervisor acknowledged the Outpatient Coding office was provided with a kick down door stop.

Based on observation and interview, the facility failed to ensure 1 of 8 fire rated stairway doors on the first floor closed and latched into the door frame. LSC 19.3.1.1 requires any vertical opening to be enclosed or protected in accordance with LSC 8.2.5. LSC 8.2.5.2 states the vertical opening shall be enclosed as appropriate for the fire resistance rating of the barrier. LSC 8.2.3.3.1 requires a one hour rated door in a one hour vertical opening. NFPA 80, the Standard for Fire Doors and Fire Windows at 2-1.2 requires fire door assemblies to include latches. NFPA 80, 2-1.4 requires fire doors to be closed and latched at the time of fire. This deficient practice could affect four patients staff and visitors in the vicinity of Stairwell # 6.

Findings include:

Based on observation on 03/19/13 with the Plant Operations Supervisor 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. Based on interview at the time of observation, the Plant Operations Supervisor 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.

Based on observation and interview, the facility 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. This deficient practice could affect an unknown number patients, staff and visitors.

Findings include:

Based on observation on 03/18/13 at 11:45 a.m. with the Plant Operations Assistant, 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. Based on interview on 03/18/13 at 11:47 a.m. it was acknowledged by the Plant Operations Assistant, the aforementioned smoke door was propped open with a flip down doorstop.

Based on observation and interview, the facility failed to ensure 14 of 14 openings through smoke barriers were protected to maintain the smoke resistance of each smoke barrier. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect an unknown number of patients, staff and/or visitors using the corridors if smoke from a fire were to infiltrate the protective barriers.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor during the tour from 10:15 a.m. to 12:15 p.m. on the second floor of the hospital, the following was noted:
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.
c. Based on observation on 03/18/13 with the Plant Operations Supervisor during the tour 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.
d. Based on observation on 03/19/13 with the Plant Operations Supervisor during the tour 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.
Based on interview at the time of the observations, the Plant Operations Supervisor acknowledged the aforementioned smoke barrier penetrations were not fire stopped.

Based on observation and interview, the facility 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. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so that the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect six patients, staff and visitors in the new surgery center.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor 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. Based on interview at the time of observation, the Plant Operation Supervisor acknowledged the pipe sleeves were not firestopped and did not know why the firestop plugs were not in place.

Based on observation and interview, the facility failed to ensure 4 of 4 pairs of cross corridor doors in the Outpatient Suite were constructed to resist the passage of smoke. This deficient practice could affect six patients, staff and visitors in the new surgery center.

Findings include:

Based on observations on 03/18/13 with the Plant Operations Supervisor 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. Based on interview at the time of observation, the Plant Operation Supervisor acknowledged the gap between the four sets of double doors would not resist the passage of smoke.

Based on observation and interview, the facility 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. This deficient practice could affect twenty patients, staff and visitors.

Findings include:

1. Based on observation on 03/18/13 with the Plant Operations Supervisor during the tour from 10:15 a.m. to 12:15 p.m. on the second floor of the hospital, the following was noted:
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.

2. Based on observation on 03/18/13 with the Plant Operations Supervisor during the tour from 1:15 p.m. to 2:45 p.m. on the first floor of the hospital, the following was noted:
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.
Based on interview at the time of observations, the lack of functioning door closing devices was acknowledged by the Plant Operations Supervisor.

3. Based on observation on 03/18/13 at 11:50 a.m. with the Plant Operations Assistant, 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. Based on interview at the time of the observation, the Plant Operations Assistant acknowledged no closing device was present on the door to the Education # 5 Storage room.

Based on observation and interview, the facility failed to maintain the vertical opening protection of 2 of 8 exit stairs. LSC 8.2.5.2 requires openings shall be protected as appropriate for the fire resistance rating of the barrier. LSC 7.1.3.2.1(a) requires a one hour rating in existing buildings of three stories or less. 7.1.3.2.1(c) requires openings in separations shall be protected by fire door assemblies. NFPA 80, the Standard for Fire Doors and Fire Windows, at 2-1.4.1 requires swinging doors to be equipped with self closing devices which will cause the door to close and latch each time it is opened. This deficient practice could affect any patient, visitor or staff using the stairwells.

Findings include:

Based on observation 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 the Plant Operations Supervisor, the following was noted:
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.
Based on interview at the time observations, the Plant Operation Supervisor acknowledged the stairwell doors had painted or missing fire door labels.

Based on observation and interview, the facility failed to ensure 1 of 2 first floor fire door sets was arranged to automatically close and latch. LSC 7.2.4.3.8 requires fire barrier doors to be self closing or automatic closing in accordance with 7.2.1.8. NFPA 80, the Standard for fire Doors and Fire Windows at 2-4.1.4 requires all closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so positive latching is achieved on each door operation. This deficient practice affects ten patients, staff, and visitors.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor 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 the Plant Operations Supervisor. 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. Based on interview at the time of observation, the Plant Operation Supervisor acknowledged the aforementioned fire doors did not close and latch.

Based on record review, observation, and interview; the facility failed to document testing of emergency lighting in accordance with LSC 7.9 for 2 of 2 battery operated emergency lights in surgery rooms. LSC 7.9.3 Periodic Testing of Emergency Lighting Equipment requires a functional test to be conducted at 30 day intervals and an annual test to be conducted on every required battery powered emergency lighting system for not less than 1 ½ -hr duration. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect two patients and staff in the in the new surgery center.

Findings include:

Based on review of "Johnson Memorial Hospital - Plant Operations Department: Lighting Emergency" documentation with the Facilities Manager during record review from 9:40 a.m. to 12:15 p.m. on 03/18/13, functional testing of two battery operated emergency lights in two surgery rooms was not available for review for October 2012 through February 2013. Based on interview at the time of record review, the Facilities Manager 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. Based on observations with the Plant Operations Supervisor during a tour of the facility from 10:30 a.m. to 11:15 a.m. on 03/19/13, battery operated lighting systems were observed in each of the two new surgery rooms.

Based on record review, observation, and interview; the facility failed to document testing of emergency lighting in accordance with LSC 7.9 for 4 of 4 battery operated emergency lights in the surgery rooms. LSC 7.9.3, Periodic Testing of Emergency Lighting Equipment, requires a functional test to be conducted at 30 day intervals for battery powered emergency lighting systems. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect four patients and staff in the facility.

Findings include:

Based on review of "Johnson Memorial Hospital - Plant Operations Department: Lighting Emergency" documentation with the Facilities Manager during record review from 9:40 a.m. to 12:15 p.m. on 03/18/13, 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. Based on interview at the time of record review, the Facilities Manager acknowledged monthly functional testing documentation for four battery operated emergency lights in four surgery rooms was not itemized for the aforementioned monthly tests. Based on observations with the Plant Operations Supervisor during a tour of the facility from 10:30 a.m. to 11:15 a.m. on 03/19/13, battery operated lighting systems were observed in each of the four surgery rooms.

1. Based on record review and interview, the facility failed to document fire drills conducted on the first and second shift for 2 of 4 quarters. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Code Red Fire Drill Critique" and "Fire Alarm Report" documentation with the Facilities Manager during record review from 9:40 a.m. to 12:15 p.m. on 03/18/13, 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. Based on interview at the time of record review, the Facilities Manager acknowledged fire drill documentation on the aforementioned shifts was not available for review.

2. Based on record review and interview, the facility failed to conduct quarterly fire drills at unexpected times under varying conditions on the third shift for 3 of 4 quarters. This deficient practice affects all patients, staff and visitors in the facility.

Findings include:

Based on review of "Code Red Fire Drill Critique" and "Fire Alarm Report" documentation with the Facilities Manager during record review from 9:40 a.m. to 12:15 p.m. on 03/18/13, 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. Based on interview at the time of record review, the Facilities Manager acknowledged the aforementioned third shift fire drills were not conducted at unexpected times under varying conditions.

Based on record review and interview, the facility failed to document fire drills conducted on the first and second shift for 1 of 4 quarters. This deficient practice could affect all patients, staff and visitors in the new surgery center.

Findings include:

Based on review of "Code Red Fire Drill Critique" and "Fire Alarm Report" documentation with the Facilities Manager during record review from 9:40 a.m. to 12:15 p.m. on 03/18/13, documentation of a fire drill conducted on the first and second shift for the third quarter of 2012 was not available for review. Based on interview at the time of record review, the Facilities Manager 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.

Based on observation and interview, the facility 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. LSC 9.6.1.3 says the provisions of 9.6 cover the basic functions of a complete fire alarm system. Section 9.6.1.4 requires fire alarm systems comply with NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect six patients, staff and visitors in the new surgery center.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor 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. Based on interview at the time of observation, this was acknowledged by the Plant Operations Supervisor.

Based on observation and interview, the facility failed to ensure 3 of over 200 smoke detectors connected to the fire alarm system were properly separated from an air supply. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where airflow prevents operation of the detectors. This deficient practice could affect six patients, staff and visitors.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor 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. Based on interview at the time of observation, the Plant Operation Supervisor 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.

Based on observation and interview, the facility failed to ensure 2 of 5 Penthouse Electrical Equipment rooms were provided with manual fire alarm boxes which were unobstructed and readily accessible. NFPA 72, National Fire Alarm Code, 2-8.2.1 states manual fire alarm boxes shall be distributed throughout the protected area so they are unobstructed, readily accessible, and located in the path of exit from the area. This deficient practice could affect two staff.

Findings include:

Based on observations on 03/18/13 between 09:45 a.m. and 11:00 a.m. with the Plant Operations Assistant, the # 1 and # 2 Penthouse Electrical Equipment rooms lacked manual fire alarm boxes for each emergency exit out of the rooms. Based on interview at the time of the observations, the Plant Operations Assistant acknowledged the aforementioned Penthouse Electrical Equipment rooms lacked a manual fire alarm box at each exit.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 1 of 1 elevator equipment rooms in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide complete coverage for all portions of the building. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main line power supply to the affected elevator automatically upon or prior to the application of water from the sprinkler located in the elevator machine room. This deficient practice could affect six patients, staff and visitors in the new surgery center.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor 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. Based on interview at the time of observation, the Plant Operations Supervisor acknowledged the new surgery elevator machine room lacked sprinkler coverage.

Based on observation and interview, 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 in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide complete coverage for all portions of the building. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main line power supply to the affected elevator automatically upon or prior to the application of water from the sprinkler located in the elevator machine room. This deficient practice could affect ten patients, staff and visitors.

Findings include:

Based on observations with the Plant Operations Assistant 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.
Based on interview on 03/18/13 at the time of the observations, it was acknowledged by the Plant Operations Assistant the aforementioned rooms lacked sprinkler coverage.

1. Based on record review and interview, the facility failed to ensure 1 of 1 automatic sprinkler systems was inspected every five years as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on record review with the Facilities Manager from 9:40 a.m. to 12:15 p.m. on 03/18/13, documentation of an internal pipe inspection for the automatic sprinkler system was not available for review. Based on interview at the time of record review, the Facilities Manager stated the automatic sprinkler system was initially installed in 1983 and acknowledged documentation of an internal pipe inspection was not available for review.

2. Based on observation and interview, the facility failed to ensure 1 of 3 automatic sprinklers in the Day Care Center "chimp" room was continuously maintained in reliable operating. 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 two staff and visitors.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor 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. Based on interview at the time of observation, the Plant Operations Supervisor acknowledged the paint on the sprinkler.

3. Based on observation and interview, the facility failed to ensure 1 of 1 automatic sprinkler systems was continuously maintained in reliable operating condition and inspected and tested periodically. NFPA 25, 2-3.2 requires gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice affects all patients, staff and visitors.

Findings include:

a. Based on observation on 03/18/13 with the Plant Operations Supervisor 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. Based on interview at the time of observation, the Plant Operation Supervisor acknowledged the gauge was manufactured in 1985.
b. Based on observation on 03/19/13 at 10:05 a.m. with the Plant Operations Assistant, 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. Based on interview on 03/19/13 at 3:20 p.m. with the Plant Operations Supervisor, it was acknowledged the pressure gauges had exceeded the five year requirement for recalibration or replacement.

Based on observation and interview, the facility failed to ensure the pressure gauge reading for 1 of 31 portable ABC class fire extinguishers on second floor was in the acceptable range. NFPA 10, the Standard for Portable Fire Extinguishers, Chapter 4-3.2(g) requires the periodic monthly check shall ensure the pressure gauge reading is in the operable range. 4-3.3.1 requires any fire extinguisher with a deficiency in any condition listed in 4-3.2 (c), (d), (e), (f) and (g) shall be subjected to applicable maintenance procedures. This deficient practice could affect ten patients, plus staff and visitors.

Findings include:

Based on observation on 03/19/13 at 10:55 a.m. with the Plant Operations Assistant, the gauge on the ABC Class portable fire extinguisher # 354 on the second floor in the Main hall indicated the extinguisher was overcharged. Based on interview on 03/19/13 at 10:56 a.m. with the Plant Operations Assistant, it was agreed the gauge reading was not in the normal operating range and he was unsure if it would affect the operation of the fire extinguisher.

Based on observation and interview, the facility failed to regulate the use of 1 of 1 portable space heaters in staff offices. This deficient practice could affect two patients, staff and visitors.

Findings include:

Based on observation on 03/19/13 at 10:55 a.m. with the Plant Operations Assistant, 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. Based on interview on 03/19/13 at 10:59 a.m., the Plant Operations Assistant acknowledged space heaters were not allowed.

Based on observation and interview, the facility failed to ensure 3 of 3 Day Care Center hanging curtains were flame retardant. This deficient practice could affect two staff and visitors.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor 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. Based on interview at the time of observation with the Plant Operation Supervisor, there was no documentation regarding flame retardancy for these curtains available for review.

1. Based on record review, observation and interview; the facility failed to ensure automatic sprinkler system components were inspected quarterly for 4 of 4 calendar quarters. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. Sprinkler systems shall be maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 1-8 requires records of inspections and tests of the sprinkler system and its components shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all patients, staff and visitors in the Johnson Memorial Intermediate Care facility.

Findings include:

Based on review of "Johnson Memorial Hospital - Plant Operations Department: ICC Sprinkler System/Monthly" documentation with the Plant Operations Supervisor during record review from 1:15 p.m. to 2:00 p.m. on 03/19/13, documentation of quarterly sprinkler system water flow alarm inspection reports for 2012 was not available for review. Based on interview at the time of record review, the Plant Operations Director 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.

2. Based on observation and interview, the facility failed to ensure 3 of 3 automatic sprinkler system's gauges were continuously maintained in reliable operating condition, inspected and tested periodically. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 25, 2-3.2 requires gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice affects all patients, staff and visitors in the Johnson Memorial Intermediate Care facility.

Findings include:

Based on observation with the Plant Operations Director 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. Based on interview at the time of record review, the Plant Operations Director 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.

3. Based on observation and interview, the facility failed to provide a complete supply of spare sprinklers and a sprinkler wrench for the automatic sprinkler system in accordance with NFPA 25, 1998 Edition, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 25, Section 2-4.1.4 requires a supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. NFPA 25, Section 2-4.1.6 states a sprinkler wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers. One sprinkler wrench shall be provided for each type of sprinkler. This deficient practice could affect all patients, staff and visitors in the Johnson Memorial Intermediate Care facility if the sprinkler system had to be shut down because a proper sprinkler wasn't available as a replacement.

Findings include:

Based on observations with the Plant Operations Director 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. Based on interview at the time of the observations, the Plant Operations Director acknowledged a spare sprinkler cabinet, spare sprinklers and sprinkler wrench were not provided for the automatic sprinkler system.

4. Based on record review, observation and interview; the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with the applicable requirements of NFPA 72, National Fire Alarm Code. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 72, 7-3.2 requires testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. Table 7-3.2 shall apply. Table 7-3.2 "Testing Frequencies" requires alarm initiating devices, alarm notification appliances, batteries, and initiating devices to be tested at least annually. This deficient practice could affect all patients, staff and visitors in the Johnson Memorial Intermediate Care facility.

Findings include:

Based on review of "Johnson Memorial Hospital-Plant Operations Department: Security System" documentation dated 08/01/12 and 11/01/12 with the Plant Operations Director during record review from 1:15 p.m. to 2:00 p.m. on 03/19/13, 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. Based on observations with the Plant Operations Director 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. Based on interview at the time of record review and of the observations, the Plant Operations Director acknowledged documentation of annual testing of facility fire alarm initiating devices, alarm notification appliances, and batteries was not available for review.

5. Based on observation, record review and interview; the facility failed to ensure 17 of 17 smoke detectors were maintained in accordance with the applicable requirements of NFPA 72, National Fire Alarm Code. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 72, 7-3.2 requires detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced. This deficient practice could affect all patients, staff and visitors in the Johnson Memorial Intermediate Care facility.

Findings include:

Based on record review with the Plant Operations Director from 1:15 p.m. to 2:00 p.m. on 03/19/13, documentation of smoke detector sensitivity testing was not available for review. Based on observations with the Plant Operations Director 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. Based on interview at the time of record review and of the observations, the Plant Operations Director acknowledged documentation of smoke detector sensitivity testing in the last two years was not available for review.

6. Based on observation and interview, the facility failed to maintain 1 of 17 smoke detectors in accordance with NFPA 72. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, smoke detectors shall not be located where airflow prevents operation of the detectors. NFPA 72, A-2-3.5.1 explains smoke detectors should not be located in a direct airflow nor closer than 3 feet from an air supply diffuser or return air opening. This deficient practice could affect 5 patients, staff and visitors at the Johnson Memorial Intermediate Care facility.

Findings include:

Based on observation with the Plant Operations Director 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. Based on interview at the time of observation, the Maintenance Director acknowledged the aforementioned smoke detector location was installed less than three feet from an air supply vent.

7. Based on observation and interview, the facility failed to properly test and maintain 1 of 1 fire alarm systems in accordance with NFPA 72. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 72, 5-5.3.2.1.6.1 requires the following: A DACT (Digital Alarm Communicator Transmitter) shall employ one of the following combinations of transmission channels:
(1) Two telephone lines (numbers)
(2) One telephone line (number) and one cellular telephone connection
(3) One telephone line (number) and a one way radio system
(4) One telephone line (number) equipped with a derived local channel
(5) One telephone line (number) and a one way private radio alarm system
(6) One telephone line (number) and a private microwave radio system
(7) One telephone line (number) and a two way RF multiplex system
(8) A single integrated services digital network (ISDN) telephone line using a terminal adapter specifically listed for supervising station fire alarm service, where the path between the transmitter and the switched telephone network serving central office is monitored for integrity so the occurrence of an adverse condition in the path shall be annunciated at the supervising station within 200 seconds. This deficient practice could affect all patients, staff and visitors at the Johnson Memorial Intermediate Care facility.

Findings include:

Based on observation with the Plant Operations Director 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. Based on interview at the time of observation, the Plant Operations Director acknowledged there is only one phone line for the main fire panel.

8. Based on observation and interview, the facility failed to ensure 1 of 6 portable fire extinguishers requiring a 12 year hydrostatic test were emptied and subjected to the applicable maintenance procedures every six years as required by NFPA 10, Standard for Portable Fire Extinguishers Chapter 4-4.3. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. Fire extinguishers passing the applicable 6-year requirement of NFPA 10, 4-4.3 shall have the maintenance information recorded on a suitable metallic label or equally durable material having a minimum size of 2 inches by 3 1/2 inches. The new label shall be affixed to the shell by a heatless process, and any old maintenance labels shall be removed. These labels shall be of the self destructive type when removal from a fire extinguisher is attempted. The label shall include the following information:
(a) Month and year the maintenance was performed, indicated by a perforation such as is done by a hand punch.
(b) Name or initials of person performing the maintenance and name of agency performing the maintenance.
NFPA 10 at Section 4-4.4.2, Verification of Service (Maintenance or Recharging) requires each extinguisher that has undergone maintenance that includes internal examination or has been recharged shall have a "Verification of Service" collar located around the neck of the container. The collar shall contain a single circular piece of uninterrupted material forming a hole of a size that will not permit the collar assembly to move over the neck of the container unless the valve is completely removed. The collar shall not interfere with the operation of the fire extinguisher. The "Verification of Service" collar shall include the month and year the service was performed, indicated by a perforation such as is done by a hand punch. This deficient practice could affect seven patients, staff and visitors at the Johnson Memorial Intermediate Care facility.

Findings include:

Based on observation with the Plant Operations Director 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. Based on interview at the time of observation, the Plant Operations Director 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.

9. Based on observation, record review and interview, the facility failed to provide documentation of periodic employee training for the use of 6 of 6 portable fire extinguishers in the facility. LSC 39.7.2 states designated employees of business occupancies shall be periodically instructed in the use of portable fire extinguishers. This deficient practice effects all patients, staff and visitors at the Johnson Memorial Intermediate Care facility.

Findings include:

Based on record review with the Plant Operations Director review from 1:15 p.m. to 2:00 p.m. on 03/19/13, documentation of designated employee training in the use of portable fire extinguishers was not available for review. Based on observations with the Plant Operations Director 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. Based on interview at the time of record review and of the observations, the Plant Operations Director acknowledged documentation of designated employee training in the use of portable fire extinguishers in the facility was not available for review.

10. Based on record review, observation and interview; the facility failed to ensure emergency lighting was tested for 16 of 16 battery operated emergency lights. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. LSC 101, Section 7.9.3 requires a functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors at the Johnson Memorial Intermediate Care facility if the facility were required to evacuate in an emergency during a loss of normal power.

Findings include:

Based on review of "Johnson Memorial Hospital-Plant Operations Department: Exit Lights in Building" documentation with the Plant Operations Director during record review from 1:15 p.m. to 2:00 p.m. on 03/19/13, documentation of an annual 90 minute test for facility battery operated lights was not available for review. Based on observations with the Plant Operations Director 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. Based on interview at the time of record review and of the observations, the Plant Operations Director acknowledged documentation of an annual 90 minute test for facility battery operated lights was not available for review.

Based on observation and interview, the facility failed to provide a one hour enclosure for 3 of 3 hazardous area storage rooms, containing combustible items which were not sprinklered. NFPA 101, Life Safety Code, 2000 Edition, Chapter 39 Section 39.3.2, Protection from Hazards, refers to Section 8.4 Special Hazard Protection, at 8.4.1.1 states Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
1. Enclose the area with a fire barrier without windows that has a one hour fire resistance rating.
2. Protect the area with automatic extinguishing systems.
3. Apply both 8.4.1.1(1) and (2) where the hazard is severe.
This deficient practice could affect two patients, staff and visitors at the Stones Crossing facility.

Findings include:

Based on observations with the Plant Operations Assistant 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.
Based on interview at the time of the observations, the Plant Operations Assistant acknowledged the aforementioned storage areas had walls with exposed interior wood studs and were not sprinklered.

Based on record review and interview, the facility failed to ensure a monthly load test for 2 of 2 emergency generators was conducted using one of the three following methods: under operating temperature conditions, at not less than 30% of the Emergency Power Supply (EPS) nameplate rating, or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of generators serving the emergency electrical system to be in accordance with NFPA 110. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations. NFPA 99, 3-5.4.2 requires a written record of inspection, performance, exercising period and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors in the new surgery center.

Findings include:

Based on review of "Johnson Memorial Hospital - Plant Operations Department: Generators" documentation with the Facilities Manager during record review from 9:40 a.m. to 12:15 p.m. on 03/18/13, 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 manufacturer. Based on interview at the time of record review, the Facilities Manager stated the new surgery center commenced operation in October 2012 and acknowledged monthly load test documentation did not include 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.

Based on record review and interview, the facility failed to ensure a monthly load test for 2 of 2 emergency generators was conducted using one of the three following methods: under operating temperature conditions, at not less than 30% of the Emergency Power Supply (EPS) nameplate rating, or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of generators serving the emergency electrical system to be in accordance with NFPA 110. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations. NFPA 99, 3-5.4.2 requires a written record of inspection, performance, exercising period and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Johnson Memorial Hospital - Plant Operations Department: Generators" documentation with the Facilities Manager during record review from 9:40 a.m. to 12:15 p.m. on 03/18/13, 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. Based on interview at the time of record review, the Facilities Manager 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.

Based on observations and interview, the facility 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. NFPA 70, National Electrical Code, 1999 Edition, 1999 Edition, Article 370-28(c) requires exposed electrical wires be confined within a junction box with a cover compatible with the box. This deficient practice could affect three staff.

Findings include:

Based on observation on 03/18/13 during the tour between 9:50 a.m. to 2:52 p.m. with the Plant Operations Assistant, 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.
Based on interview on 03/18/13 at the time of the observations, the Plant Operations Assistant acknowledged the aforementioned electrical junction boxes were not protected with a cover.

Based on record review and interview, the facility 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 in accordance with LSC, Section 9.7.6.1 in order to protect 44 of 125 patients. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, 1998 Edition, the Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 11-5(c) states where a required fire protection system is out of service for more than 4 hours in a 24 hour period, an impairment coordinator shall evacuate the building or establish an approved fire watch. Section 11-5(d) requires the local fire department be notified of sprinkler impairment and Section 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 patients, staff and visitors in the new surgery center.

Findings include:

Based on review of "Johnson Memorial Hospital Safety Policy: Utility Failures" documentation with the Facilities Manager during record review from 9:40 a.m. to 12:15 p.m. on 03/18/13, 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.
Based on interview at the time of record review, the Facilities Manager stated no additional fire watch documentation was available for review and acknowledged the written fire watch policy did not include the aforementioned statements.

Based on record review and interview, the facility 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 in accordance with LSC, Section 9.7.6.1 in order to protect 44 of 125 patients. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, 1998 Edition, the Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 11-5(c) states where a required fire protection system is out of service for more than 4 hours in a 24 hour period, an impairment coordinator shall evacuate the building or establish an approved fire watch. Section 11-5(d) requires the local fire department be notified of sprinkler impairment and Section 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 patients, staff and visitors.

Findings include:

Based on review of "Johnson Memorial Hospital Safety Policy: Utility Failures" documentation with the Facilities Manager during record review from 9:40 a.m. to 12:15 p.m. on 03/18/13, 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.
Based on interview at the time of record review, the Facilities Manager stated no additional fire watch documentation was available for review and acknowledged the written fire watch policy did not include the aforementioned statements.

Based on record review and staff interview, the facility 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 in accordance with LSC, Section 9.6.1.8 in order to protect 44 of 125 patients. This deficient practice could affect all patients, staff and visitors in the new surgery center.

Findings include:

Based on review of "Johnson Memorial Hospital Safety Policy: Utility Failures" documentation with the Facilities Manager during record review from 9:40 a.m. to 12:15 p.m. on 03/18/13, 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.
Based on interview at the time of record review, the Facilities Manager stated no additional fire watch documentation was available for review and acknowledged the written fire watch policy did not include the aforementioned statements.

Based on record review and staff interview, the facility 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 in accordance with LSC, Section 9.6.1.8 in order to protect 44 of 125 patients. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Johnson Memorial Hospital Safety Policy: Utility Failures" documentation with the Facilities Manager during record review from 9:40 a.m. to 12:15 p.m. on 03/18/13, 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.
Based on interview at the time of record review, the Facilities Manager stated no additional fire watch documentation was available for review and acknowledged the written fire watch policy did not include the aforementioned statements.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 1 of 1 elevator equipment rooms in this two story building of Type II (222) construction which is required to be sprinklered. This deficient practice could affect six patients, staff and visitors in the new surgery center.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor 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. Based on interview at the time of observation, the Plant Operations Supervisor acknowledged the new surgery elevator machine room lacked sprinkler coverage.

Based on observation and interview, 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 in this three story building of Type II (111) which is required to be fully sprinklered. This deficient practice could affect ten patients, staff and visitors.

Findings include:

Based on observations with the Plant Operations Assistant on 03/18/13 during the tour 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.
Based on interview on 03/18/13 at the time of the observations, it was acknowledged by the Plant Operations Assistant the aforementioned rooms lacked sprinkler coverage.

Based on observation and interview, the facility failed to ensure 4 of 4 open use areas were separated from the corridor, or met an Exception. LSC 19.3.6.1, Exception # 1, Spaces shall be permitted to be unlimited in area and open to the corridor, provided the following criteria are met: (a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas. (b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the smoke compartment in which the space is located is protected throughout by quick response sprinklers. (c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space. (d) The space does not obstruct access to required exits. This deficient practice affects an unknown number of patients, staff and/or visitors.

Findings include:

a. Based on observation on 03/18/13 during the tour from 1:15 p.m. to 2:45 p.m. with the Plant Operations Supervisor, the first floor canteen was open to the corridors. Furthermore, Exception # 1, requirement (b) and (c) of the Life Safety Code, Chapter 19.3.6.1 was not met as follows: the open area and the corridor to which the canteen was open to in the same smoke compartment was not protected by an automatic smoke detection system or arranged to allow direct supervision by facility staff from a continuously staffed area such as a nurses' station. Based on interview at the time of observation, the Plant Operation Supervisor 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.
b. Based on observation on 03/18/13 during the tour from 2:27 p.m. to 2:52 p.m. with the Plant Operations Assistant, the first floor Wheelchair storage room and the two third floor Pantry rooms were open to the corridors. Furthermore, Exception # 1, requirement (b) and (c) of the Life Safety Code, Chapter 19.3.6.1 were not met as follows: the open area and the corridor to which the Wheelchair room and Pantry rooms were open to in the same smoke compartment were not protected by an automatic smoke detection system or arranged to allow direct supervision by facility staff from a continuously staffed area such as a nurses' station. Based on interview on 03/18/13 at the time of the observations, the Plant Operation Assistant 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.

1. Based on observation and interview, the facility failed to ensure 1 of 20 corridor doors in the Maternity Center were provided with a means suitable for keeping the door closed. This deficient practice could affect two patients, staff and visitors.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor during the tour 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. Based on interview at the time of observation, the Plant Operations Supervisor acknowledged the C-section room door was not provided with a latching mechanism.

2. Based on observation and interview, the facility failed to ensure 4 of 20 corridor doors in the Maternity Center would resist the passage of smoke. This deficient practice could affect two patients, staff and visitors.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor during the tour 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. Based on interview at the time of observation, the Plant Operations Supervisor acknowledged the above mentioned room doors had holes through the doors and were not smoke resistant.

3. Based on observation and interview, the facility failed to ensure 1 of 1 Outpatient Coding office doors protecting corridor openings did not have an impediment to the closing of the door. This deficient practice could affect two staff and visitors.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor during the tour 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. Based on interview at the time of observation, the Plant Operations Supervisor acknowledged the Outpatient Coding office was provided with a kick down door stop.

Based on observation and interview, the facility failed to ensure 1 of 8 fire rated stairway doors on the first floor closed and latched into the door frame. LSC 19.3.1.1 requires any vertical opening to be enclosed or protected in accordance with LSC 8.2.5. LSC 8.2.5.2 states the vertical opening shall be enclosed as appropriate for the fire resistance rating of the barrier. LSC 8.2.3.3.1 requires a one hour rated door in a one hour vertical opening. NFPA 80, the Standard for Fire Doors and Fire Windows at 2-1.2 requires fire door assemblies to include latches. NFPA 80, 2-1.4 requires fire doors to be closed and latched at the time of fire. This deficient practice could affect four patients staff and visitors in the vicinity of Stairwell # 6.

Findings include:

Based on observation on 03/19/13 with the Plant Operations Supervisor 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. Based on interview at the time of observation, the Plant Operations Supervisor 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.

Based on observation and interview, the facility 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. This deficient practice could affect an unknown number patients, staff and visitors.

Findings include:

Based on observation on 03/18/13 at 11:45 a.m. with the Plant Operations Assistant, 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. Based on interview on 03/18/13 at 11:47 a.m. it was acknowledged by the Plant Operations Assistant, the aforementioned smoke door was propped open with a flip down doorstop.

Based on observation and interview, the facility failed to ensure 14 of 14 openings through smoke barriers were protected to maintain the smoke resistance of each smoke barrier. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect an unknown number of patients, staff and/or visitors using the corridors if smoke from a fire were to infiltrate the protective barriers.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor during the tour from 10:15 a.m. to 12:15 p.m. on the second floor of the hospital, the following was noted:
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.
c. Based on observation on 03/18/13 with the Plant Operations Supervisor during the tour 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.
d. Based on observation on 03/19/13 with the Plant Operations Supervisor during the tour 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.
Based on interview at the time of the observations, the Plant Operations Supervisor acknowledged the aforementioned smoke barrier penetrations were not fire stopped.

Based on observation and interview, the facility 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. LSC Section 8.3.6.1 requires the passage of building service materials such as pipe, cable or wire to be protected so that the space between the penetrating item and the smoke barrier shall be filled with a material capable of maintaining the smoke resistance of the smoke barrier or be protected by an approved device designed for the specific purpose. This deficient practice could affect six patients, staff and visitors in the new surgery center.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor 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. Based on interview at the time of observation, the Plant Operation Supervisor acknowledged the pipe sleeves were not firestopped and did not know why the firestop plugs were not in place.

Based on observation and interview, the facility failed to ensure 4 of 4 pairs of cross corridor doors in the Outpatient Suite were constructed to resist the passage of smoke. This deficient practice could affect six patients, staff and visitors in the new surgery center.

Findings include:

Based on observations on 03/18/13 with the Plant Operations Supervisor 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. Based on interview at the time of observation, the Plant Operation Supervisor acknowledged the gap between the four sets of double doors would not resist the passage of smoke.

Based on observation and interview, the facility 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. This deficient practice could affect twenty patients, staff and visitors.

Findings include:

1. Based on observation on 03/18/13 with the Plant Operations Supervisor during the tour from 10:15 a.m. to 12:15 p.m. on the second floor of the hospital, the following was noted:
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.

2. Based on observation on 03/18/13 with the Plant Operations Supervisor during the tour from 1:15 p.m. to 2:45 p.m. on the first floor of the hospital, the following was noted:
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.
Based on interview at the time of observations, the lack of functioning door closing devices was acknowledged by the Plant Operations Supervisor.

3. Based on observation on 03/18/13 at 11:50 a.m. with the Plant Operations Assistant, 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. Based on interview at the time of the observation, the Plant Operations Assistant acknowledged no closing device was present on the door to the Education # 5 Storage room.

Based on observation and interview, the facility failed to maintain the vertical opening protection of 2 of 8 exit stairs. LSC 8.2.5.2 requires openings shall be protected as appropriate for the fire resistance rating of the barrier. LSC 7.1.3.2.1(a) requires a one hour rating in existing buildings of three stories or less. 7.1.3.2.1(c) requires openings in separations shall be protected by fire door assemblies. NFPA 80, the Standard for Fire Doors and Fire Windows, at 2-1.4.1 requires swinging doors to be equipped with self closing devices which will cause the door to close and latch each time it is opened. This deficient practice could affect any patient, visitor or staff using the stairwells.

Findings include:

Based on observation 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 the Plant Operations Supervisor, the following was noted:
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.
Based on interview at the time observations, the Plant Operation Supervisor acknowledged the stairwell doors had painted or missing fire door labels.

Based on observation and interview, the facility failed to ensure 1 of 2 first floor fire door sets was arranged to automatically close and latch. LSC 7.2.4.3.8 requires fire barrier doors to be self closing or automatic closing in accordance with 7.2.1.8. NFPA 80, the Standard for fire Doors and Fire Windows at 2-4.1.4 requires all closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so positive latching is achieved on each door operation. This deficient practice affects ten patients, staff, and visitors.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor 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 the Plant Operations Supervisor. 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. Based on interview at the time of observation, the Plant Operation Supervisor acknowledged the aforementioned fire doors did not close and latch.

Based on record review, observation, and interview; the facility failed to document testing of emergency lighting in accordance with LSC 7.9 for 2 of 2 battery operated emergency lights in surgery rooms. LSC 7.9.3 Periodic Testing of Emergency Lighting Equipment requires a functional test to be conducted at 30 day intervals and an annual test to be conducted on every required battery powered emergency lighting system for not less than 1 ½ -hr duration. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect two patients and staff in the in the new surgery center.

Findings include:

Based on review of "Johnson Memorial Hospital - Plant Operations Department: Lighting Emergency" documentation with the Facilities Manager during record review from 9:40 a.m. to 12:15 p.m. on 03/18/13, functional testing of two battery operated emergency lights in two surgery rooms was not available for review for October 2012 through February 2013. Based on interview at the time of record review, the Facilities Manager 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. Based on observations with the Plant Operations Supervisor during a tour of the facility from 10:30 a.m. to 11:15 a.m. on 03/19/13, battery operated lighting systems were observed in each of the two new surgery rooms.

Based on record review, observation, and interview; the facility failed to document testing of emergency lighting in accordance with LSC 7.9 for 4 of 4 battery operated emergency lights in the surgery rooms. LSC 7.9.3, Periodic Testing of Emergency Lighting Equipment, requires a functional test to be conducted at 30 day intervals for battery powered emergency lighting systems. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect four patients and staff in the facility.

Findings include:

Based on review of "Johnson Memorial Hospital - Plant Operations Department: Lighting Emergency" documentation with the Facilities Manager during record review from 9:40 a.m. to 12:15 p.m. on 03/18/13, 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. Based on interview at the time of record review, the Facilities Manager acknowledged monthly functional testing documentation for four battery operated emergency lights in four surgery rooms was not itemized for the aforementioned monthly tests. Based on observations with the Plant Operations Supervisor during a tour of the facility from 10:30 a.m. to 11:15 a.m. on 03/19/13, battery operated lighting systems were observed in each of the four surgery rooms.

1. Based on record review and interview, the facility failed to document fire drills conducted on the first and second shift for 2 of 4 quarters. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Code Red Fire Drill Critique" and "Fire Alarm Report" documentation with the Facilities Manager during record review from 9:40 a.m. to 12:15 p.m. on 03/18/13, 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. Based on interview at the time of record review, the Facilities Manager acknowledged fire drill documentation on the aforementioned shifts was not available for review.

2. Based on record review and interview, the facility failed to conduct quarterly fire drills at unexpected times under varying conditions on the third shift for 3 of 4 quarters. This deficient practice affects all patients, staff and visitors in the facility.

Findings include:

Based on review of "Code Red Fire Drill Critique" and "Fire Alarm Report" documentation with the Facilities Manager during record review from 9:40 a.m. to 12:15 p.m. on 03/18/13, 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. Based on interview at the time of record review, the Facilities Manager acknowledged the aforementioned third shift fire drills were not conducted at unexpected times under varying conditions.

Based on record review and interview, the facility failed to document fire drills conducted on the first and second shift for 1 of 4 quarters. This deficient practice could affect all patients, staff and visitors in the new surgery center.

Findings include:

Based on review of "Code Red Fire Drill Critique" and "Fire Alarm Report" documentation with the Facilities Manager during record review from 9:40 a.m. to 12:15 p.m. on 03/18/13, documentation of a fire drill conducted on the first and second shift for the third quarter of 2012 was not available for review. Based on interview at the time of record review, the Facilities Manager 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.

Based on observation and interview, the facility 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. LSC 9.6.1.3 says the provisions of 9.6 cover the basic functions of a complete fire alarm system. Section 9.6.1.4 requires fire alarm systems comply with NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect six patients, staff and visitors in the new surgery center.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor 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. Based on interview at the time of observation, this was acknowledged by the Plant Operations Supervisor.

Based on observation and interview, the facility failed to ensure 3 of over 200 smoke detectors connected to the fire alarm system were properly separated from an air supply. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where airflow prevents operation of the detectors. This deficient practice could affect six patients, staff and visitors.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor 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. Based on interview at the time of observation, the Plant Operation Supervisor 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.

Based on observation and interview, the facility failed to ensure 2 of 5 Penthouse Electrical Equipment rooms were provided with manual fire alarm boxes which were unobstructed and readily accessible. NFPA 72, National Fire Alarm Code, 2-8.2.1 states manual fire alarm boxes shall be distributed throughout the protected area so they are unobstructed, readily accessible, and located in the path of exit from the area. This deficient practice could affect two staff.

Findings include:

Based on observations on 03/18/13 between 09:45 a.m. and 11:00 a.m. with the Plant Operations Assistant, the # 1 and # 2 Penthouse Electrical Equipment rooms lacked manual fire alarm boxes for each emergency exit out of the rooms. Based on interview at the time of the observations, the Plant Operations Assistant acknowledged the aforementioned Penthouse Electrical Equipment rooms lacked a manual fire alarm box at each exit.

Based on observation and interview, the facility failed to ensure a complete automatic sprinkler system was provided for 1 of 1 elevator equipment rooms in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide complete coverage for all portions of the building. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main line power supply to the affected elevator automatically upon or prior to the application of water from the sprinkler located in the elevator machine room. This deficient practice could affect six patients, staff and visitors in the new surgery center.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor 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. Based on interview at the time of observation, the Plant Operations Supervisor acknowledged the new surgery elevator machine room lacked sprinkler coverage.

Based on observation and interview, 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 in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide complete coverage for all portions of the building. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be ordinary or intermediate temperature rating. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main line power supply to the affected elevator automatically upon or prior to the application of water from the sprinkler located in the elevator machine room. This deficient practice could affect ten patients, staff and visitors.

Findings include:

Based on observations with the Plant Operations Assistant 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.
Based on interview on 03/18/13 at the time of the observations, it was acknowledged by the Plant Operations Assistant the aforementioned rooms lacked sprinkler coverage.

1. Based on record review and interview, the facility failed to ensure 1 of 1 automatic sprinkler systems was inspected every five years as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on record review with the Facilities Manager from 9:40 a.m. to 12:15 p.m. on 03/18/13, documentation of an internal pipe inspection for the automatic sprinkler system was not available for review. Based on interview at the time of record review, the Facilities Manager stated the automatic sprinkler system was initially installed in 1983 and acknowledged documentation of an internal pipe inspection was not available for review.

2. Based on observation and interview, the facility failed to ensure 1 of 3 automatic sprinklers in the Day Care Center "chimp" room was continuously maintained in reliable operating. 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 two staff and visitors.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor 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. Based on interview at the time of observation, the Plant Operations Supervisor acknowledged the paint on the sprinkler.

3. Based on observation and interview, the facility failed to ensure 1 of 1 automatic sprinkler systems was continuously maintained in reliable operating condition and inspected and tested periodically. NFPA 25, 2-3.2 requires gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice affects all patients, staff and visitors.

Findings include:

a. Based on observation on 03/18/13 with the Plant Operations Supervisor 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. Based on interview at the time of observation, the Plant Operation Supervisor acknowledged the gauge was manufactured in 1985.
b. Based on observation on 03/19/13 at 10:05 a.m. with the Plant Operations Assistant, 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. Based on interview on 03/19/13 at 3:20 p.m. with the Plant Operations Supervisor, it was acknowledged the pressure gauges had exceeded the five year requirement for recalibration or replacement.

Based on observation and interview, the facility failed to ensure the pressure gauge reading for 1 of 31 portable ABC class fire extinguishers on second floor was in the acceptable range. NFPA 10, the Standard for Portable Fire Extinguishers, Chapter 4-3.2(g) requires the periodic monthly check shall ensure the pressure gauge reading is in the operable range. 4-3.3.1 requires any fire extinguisher with a deficiency in any condition listed in 4-3.2 (c), (d), (e), (f) and (g) shall be subjected to applicable maintenance procedures. This deficient practice could affect ten patients, plus staff and visitors.

Findings include:

Based on observation on 03/19/13 at 10:55 a.m. with the Plant Operations Assistant, the gauge on the ABC Class portable fire extinguisher # 354 on the second floor in the Main hall indicated the extinguisher was overcharged. Based on interview on 03/19/13 at 10:56 a.m. with the Plant Operations Assistant, it was agreed the gauge reading was not in the normal operating range and he was unsure if it would affect the operation of the fire extinguisher.

Based on observation and interview, the facility failed to regulate the use of 1 of 1 portable space heaters in staff offices. This deficient practice could affect two patients, staff and visitors.

Findings include:

Based on observation on 03/19/13 at 10:55 a.m. with the Plant Operations Assistant, 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. Based on interview on 03/19/13 at 10:59 a.m., the Plant Operations Assistant acknowledged space heaters were not allowed.

Based on observation and interview, the facility failed to ensure 3 of 3 Day Care Center hanging curtains were flame retardant. This deficient practice could affect two staff and visitors.

Findings include:

Based on observation on 03/18/13 with the Plant Operations Supervisor 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. Based on interview at the time of observation with the Plant Operation Supervisor, there was no documentation regarding flame retardancy for these curtains available for review.

1. Based on record review, observation and interview; the facility failed to ensure automatic sprinkler system components were inspected quarterly for 4 of 4 calendar quarters. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. Sprinkler systems shall be maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 1-8 requires records of inspections and tests of the sprinkler system and its components shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all patients, staff and visitors in the Johnson Memorial Intermediate Care facility.

Findings include:

Based on review of "Johnson Memorial Hospital - Plant Operations Department: ICC Sprinkler System/Monthly" documentation with the Plant Operations Supervisor during record review from 1:15 p.m. to 2:00 p.m. on 03/19/13, documentation of quarterly sprinkler system water flow alarm inspection reports for 2012 was not available for review. Based on interview at the time of record review, the Plant Operations Director 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.

2. Based on observation and interview, the facility failed to ensure 3 of 3 automatic sprinkler system's gauges were continuously maintained in reliable operating condition, inspected and tested periodically. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 25, 2-3.2 requires gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice affects all patients, staff and visitors in the Johnson Memorial Intermediate Care facility.

Findings include:

Based on observation with the Plant Operations Director 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. Based on interview at the time of record review, the Plant Operations Director 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.

3. Based on observation and interview, the facility failed to provide a complete supply of spare sprinklers and a sprinkler wrench for the automatic sprinkler system in accordance with NFPA 25, 1998 Edition, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 25, Section 2-4.1.4 requires a supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. NFPA 25, Section 2-4.1.6 states a sprinkler wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers. One sprinkler wrench shall be provided for each type of sprinkler. This deficient practice could affect all patients, staff and visitors in the Johnson Memorial Intermediate Care facility if the sprinkler system had to be shut down because a proper sprinkler wasn't available as a replacement.

Findings include:

Based on observations with the Plant Operations Director 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. Based on interview at the time of the observations, the Plant Operations Director acknowledged a spare sprinkler cabinet, spare sprinklers and sprinkler wrench were not provided for the automatic sprinkler system.

4. Based on record review, observation and interview; the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with the applicable requirements of NFPA 72, National Fire Alarm Code. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 72, 7-3.2 requires testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. Table 7-3.2 shall apply. Table 7-3.2 "Testing Frequencies" requires alarm initiating devices, alarm notification appliances, batteries, and initiating devices to be tested at least annually. This deficient practice could affect all patients, staff and visitors in the Johnson Memorial Intermediate Care facility.

Findings include:

Based on review of "Johnson Memorial Hospital-Plant Operations Department: Security System" documentation dated 08/01/12 and 11/01/12 with the Plant Operations Director during record review from 1:15 p.m. to 2:00 p.m. on 03/19/13, 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. Based on observations with the Plant Operations Director 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. Based on interview at the time of record review and of the observations, the Plant Operations Director acknowledged documentation of annual testing of facility fire alarm initiating devices, alarm notification appliances, and batteries was not available for review.

5. Based on observation, record review and interview; the facility failed to ensure 17 of 17 smoke detectors were maintained in accordance with the applicable requirements of NFPA 72, National Fire Alarm Code. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 72, 7-3.2 requires detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced. This deficient practice could affect all patients, staff and visitors in the Johnson Memorial Intermediate Care facility.

Findings include:

Based on record review with the Plant Operations Director from 1:15 p.m. to 2:00 p.m. on 03/19/13, documentation of smoke detector sensitivity testing was not available for review. Based on observations with the Plant Operations Director 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. Based on interview at the time of record review and of the observations, the Plant Operations Director acknowledged documentation of smoke detector sensitivity testing in the last two years was not available for review.

6. Based on observation and interview, the facility failed to maintain 1 of 17 smoke detectors in accordance with NFPA 72. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, smoke detectors shall not be located where airflow prevents operation of the detectors. NFPA 72, A-2-3.5.1 explains smoke detectors should not be located in a direct airflow nor closer than 3 feet from an air supply diffuser or return air opening. This deficient practice could affect 5 patients, staff and visitors at the Johnson Memorial Intermediate Care facility.

Findings include:

Based on observation with the Plant Operations Director 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. Based on interview at the time of observation, the Maintenance Director acknowledged the aforementioned smoke detector location was installed less than three feet from an air supply vent.

7. Based on observation and interview, the facility failed to properly test and maintain 1 of 1 fire alarm systems in accordance with NFPA 72. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. NFPA 72, 5-5.3.2.1.6.1 requires the following: A DACT (Digital Alarm Communicator Transmitter) shall employ one of the following combinations of transmission channels:
(1) Two telephone lines (numbers)
(2) One telephone line (number) and one cellular telephone connection
(3) One telephone line (number) and a one way radio system
(4) One telephone line (number) equipped with a derived local channel
(5) One telephone line (number) and a one way private radio alarm system
(6) One telephone line (number) and a private microwave radio system
(7) One telephone line (number) and a two way RF multiplex system
(8) A single integrated services digital network (ISDN) telephone line using a terminal adapter specifically listed for supervising station fire alarm service, where the path between the transmitter and the switched telephone network serving central office is monitored for integrity so the occurrence of an adverse condition in the path shall be annunciated at the supervising station within 200 seconds. This deficient practice could affect all patients, staff and visitors at the Johnson Memorial Intermediate Care facility.

Findings include:

Based on observation with the Plant Operations Director 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. Based on interview at the time of observation, the Plant Operations Director acknowledged there is only one phone line for the main fire panel.

8. Based on observation and interview, the facility failed to ensure 1 of 6 portable fire extinguishers requiring a 12 year hydrostatic test were emptied and subjected to the applicable maintenance procedures every six years as required by NFPA 10, Standard for Portable Fire Extinguishers Chapter 4-4.3. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. Fire extinguishers passing the applicable 6-year requirement of NFPA 10, 4-4.3 shall have the maintenance information recorded on a suitable metallic label or equally durable material having a minimum size of 2 inches by 3 1/2 inches. The new label shall be affixed to the shell by a heatless process, and any old maintenance labels shall be removed. These labels shall be of the self destructive type when removal from a fire extinguisher is attempted. The label shall include the following information:
(a) Month and year the maintenance was performed, indicated by a perforation such as is done by a hand punch.
(b) Name or initials of person performing the maintenance and name of agency performing the maintenance.
NFPA 10 at Section 4-4.4.2, Verification of Service (Maintenance or Recharging) requires each extinguisher that has undergone maintenance that includes internal examination or has been recharged shall have a "Verification of Service" collar located around the neck of the container. The collar shall contain a single circular piece of uninterrupted material forming a hole of a size that will not permit the collar assembly to move over the neck of the container unless the valve is completely removed. The collar shall not interfere with the operation of the fire extinguisher. The "Verification of Service" collar shall include the month and year the service was performed, indicated by a perforation such as is done by a hand punch. This deficient practice could affect seven patients, staff and visitors at the Johnson Memorial Intermediate Care facility.

Findings include:

Based on observation with the Plant Operations Director 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. Based on interview at the time of observation, the Plant Operations Director 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.

9. Based on observation, record review and interview, the facility failed to provide documentation of periodic employee training for the use of 6 of 6 portable fire extinguishers in the facility. LSC 39.7.2 states designated employees of business occupancies shall be periodically instructed in the use of portable fire extinguishers. This deficient practice effects all patients, staff and visitors at the Johnson Memorial Intermediate Care facility.

Findings include:

Based on record review with the Plant Operations Director review from 1:15 p.m. to 2:00 p.m. on 03/19/13, documentation of designated employee training in the use of portable fire extinguishers was not available for review. Based on observations with the Plant Operations Director 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. Based on interview at the time of record review and of the observations, the Plant Operations Director acknowledged documentation of designated employee training in the use of portable fire extinguishers in the facility was not available for review.

10. Based on record review, observation and interview; the facility failed to ensure emergency lighting was tested for 16 of 16 battery operated emergency lights. LSC 4.6.12.2 states life safety features obvious to the public, even if not required, shall be maintained or removed. LSC 101, Section 7.9.3 requires a functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors at the Johnson Memorial Intermediate Care facility if the facility were required to evacuate in an emergency during a loss of normal power.

Findings include:

Based on review of "Johnson Memorial Hospital-Plant Operations Department: Exit Lights in Building" documentation with the Plant Operations Director during record review from 1:15 p.m. to 2:00 p.m. on 03/19/13, documentation of an annual 90 minute test for facility battery operated lights was not available for review. Based on observations with the Plant Operations Director 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. Based on interview at the time of record review and of the observations, the Plant Operations Director acknowledged documentation of an annual 90 minute test for facility battery operated lights was not available for review.

Based on observation and interview, the facility failed to provide a one hour enclosure for 3 of 3 hazardous area storage rooms, containing combustible items which were not sprinklered. NFPA 101, Life Safety Code, 2000 Edition, Chapter 39 Section 39.3.2, Protection from Hazards, refers to Section 8.4 Special Hazard Protection, at 8.4.1.1 states Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
1. Enclose the area with a fire barrier without windows that has a one hour fire resistance rating.
2. Protect the area with automatic extinguishing systems.
3. Apply both 8.4.1.1(1) and (2) where the hazard is severe.
This deficient practice could affect two patients, staff and visitors at the Stones Crossing facility.

Findings include:

Based on observations with the Plant Operations Assistant 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.
Based on interview at the time of the observations, the Plant Operations Assistant acknowledged the aforementioned storage areas had walls with exposed interior wood studs and were not sprinklered.

Based on record review and interview, the facility failed to ensure a monthly load test for 2 of 2 emergency generators was conducted using one of the three following methods: under operating temperature conditions, at not less than 30% of the Emergency Power Supply (EPS) nameplate rating, or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of generators serving the emergency electrical system to be in accordance with NFPA 110. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations. NFPA 99, 3-5.4.2 requires a written record of inspection, performance, exercising period and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors in the new surgery center.

Findings include:

Based on review of "Johnson Memorial Hospital - Plant Operations Department: Generators" documentation with the Facilities Manager during record review from 9:40 a.m. to 12:15 p.m. on 03/18/13, 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 manufacturer. Based on interview at the time of record review, the Facilities Manager stated the new surgery center commenced operation in October 2012 and acknowledged monthly load test documentation did not include 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.

Based on record review and interview, the facility failed to ensure a monthly load test for 2 of 2 emergency generators was conducted using one of the three following methods: under operating temperature conditions, at not less than 30% of the Emergency Power Supply (EPS) nameplate rating, or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. Chapter 3-4.4.1.1 of NFPA 99 requires monthly testing of generators serving the emergency electrical system to be in accordance with NFPA 110. Chapter 6-4.2 of NFPA 110 requires generator sets in Level 1 and Level 2 service to be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
a. Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
b. Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations. NFPA 99, 3-5.4.2 requires a written record of inspection, performance, exercising period and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Johnson Memorial Hospital - Plant Operations Department: Generators" documentation with the Facilities Manager during record review from 9:40 a.m. to 12:15 p.m. on 03/18/13, 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. Based on interview at the time of record review, the Facilities Manager 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.

Based on observations and interview, the facility 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. NFPA 70, National Electrical Code, 1999 Edition, 1999 Edition, Article 370-28(c) requires exposed electrical wires be confined within a junction box with a cover compatible with the box. This deficient practice could affect three staff.

Findings include:

Based on observation on 03/18/13 during the tour between 9:50 a.m. to 2:52 p.m. with the Plant Operations Assistant, 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.
Based on interview on 03/18/13 at the time of the observations, the Plant Operations Assistant acknowledged the aforementioned electrical junction boxes were not protected with a cover.

Based on record review and interview, the facility 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 in accordance with LSC, Section 9.7.6.1 in order to protect 44 of 125 patients. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, 1998 Edition, the Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 11-5(c) states where a required fire protection system is out of service for more than 4 hours in a 24 hour period, an impairment coordinator shall evacuate the building or establish an approved fire watch. Section 11-5(d) requires the local fire department be notified of sprinkler impairment and Section 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 patients, staff and visitors in the new surgery center.

Findings include:

Based on review of "Johnson Memorial Hospital Safety Policy: Utility Failures" documentation with the Facilities Manager during record review from 9:40 a.m. to 12:15 p.m. on 03/18/13, 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.
Based on interview at the time of record review, the Facilities Manager stated no additional fire watch documentation was available for review and acknowledged the written fire watch policy did not include the aforementioned statements.

Based on record review and interview, the facility 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 in accordance with LSC, Section 9.7.6.1 in order to protect 44 of 125 patients. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, 1998 Edition, the Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 11-5(c) states where a required fire protection system is out of service for more than 4 hours in a 24 hour period, an impairment coordinator shall evacuate the building or establish an approved fire watch. Section 11-5(d) requires the local fire department be notified of sprinkler impairment and Section 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 patients, staff and visitors.

Findings include:

Based on review of "Johnson Memorial Hospital Safety Policy: Utility Failures" documentation with the Facilities Manager during record review from 9:40 a.m. to 12:15 p.m. on 03/18/13, 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.
Based on interview at the time of record review, the Facilities Manager stated no additional fire watch documentation was available for review and acknowledged the written fire watch policy did not include the aforementioned statements.

Based on record review and staff interview, the facility 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 in accordance with LSC, Section 9.6.1.8 in order to protect 44 of 125 patients. This deficient practice could affect all patients, staff and visitors in the new surgery center.

Findings include:

Based on review of "Johnson Memorial Hospital Safety Policy: Utility Failures" documentation with the Facilities Manager during record review from 9:40 a.m. to 12:15 p.m. on 03/18/13, 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.
Based on interview at the time of record review, the Facilities Manager stated no additional fire watch documentation was available for review and acknowledged the written fire watch policy did not include the aforementioned statements.

Based on record review and staff interview, the facility 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 in accordance with LSC, Section 9.6.1.8 in order to protect 44 of 125 patients. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Johnson Memorial Hospital Safety Policy: Utility Failures" documentation with the Facilities Manager during record review from 9:40 a.m. to 12:15 p.m. on 03/18/13, 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.
Based on interview at the time of record review, the Facilities Manager stated no additional fire watch documentation was available for review and acknowledged the written fire watch policy did not include the aforementioned statements.