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Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures include a system to track the location of on-duty staff and sheltered residents in the Hospital's care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the Hospital must document the specific name and location of the receiving facility or other location in accordance with 42 CFR 482.15(b)(2). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Facility Manager on 08/29/18 between 9:41 a.m. and 2:45 p.m., no policies and procedures that include a system to track the location of on-duty staff and sheltered patients in the hospital's care during and after an emergency was available for review. Based on interview at the time of record review then again at the exit conference, the Maintenance Director confirmed there was a policy and procedure for tracking staff and patients but was not documented and available to review.

Based on record review and interview, the facility failed to ensure emergency preparedness policies and procedures include a means to shelter in place for residents, staff, and volunteers who remain in the Hospital in accordance with 42 CFR 482.15(b)(4). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Facility Manager on 08/29/18 between 9:41 a.m. and 2:45 p.m., a policy and procedure that included a means to shelter in place for patients, staff, and volunteers who remain in the hospital was not available for review. Based on interview at the time of record review then again at the exit conference, the Maintenance Director described a shelter in place policy and procedure but no documentation described a specific plan to shelter in place was available to review.

1. Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm panel was protected in accordance with 21.3.4.1. NFPA 72, National Fire Alarm and Signaling Code 10.15* Protection of Fire Alarm System. In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s), notification appliance circuit power extenders, and supervising station transmitting equipment to provide notification of fire at that location. Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Maintenance Director on 08/29/18 between 9:41 a.m. and 2:45 p.m., the fire alarm panel did not have a smoke detector above it. Based on an interview at the time of observation, the Maintenance Director confirmed no smoke detector was provided for the fire alarm control panel.

2. Based on observation and interview, the facility failed to maintain 1 of 1 multiplug adapter according to 9.1. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could affect staff only.

Findings include:

Based on observation with the Maintenance Director on 08/29/18 between 9:41 a.m. and 2:45 p.m., a multiplug adapter was powering computer components in the 2nd floor Reception area. Based on interview at the time of observation, the Maintenance Director confirmed the improper multiplug use.

Based on observation and interview, the facility to maintain the limited noncombustible rating in accordance with Table 19.1.6.1. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/29/18 at 2:35 p.m., there were exposed steel support beams in the Medical Vacuum room with multiple spots measuring a total of two square feet where the protective coating was removed. Based on an interview at the time of observation, the Director of Facilities and the Maintenance Technician #1 confirmed that bare metal was exposed and provided the estimate square feet of exposed metal.

Based on observation, the facility failed to ensure 2 of 2 4th floor public bathrooms could be readily unlocked in accordance with LSC 19.2.2.2.6 which allows doors that are located in the means of egress and are permitted to be locked under other provisions of 19.2.2.2.5 shall comply with the following. (1) Provisions shall be made for the rapid removal of occupants by means of one of the following: (a) Remote control of locks (b) Keying of all locks to keys carried by staff at all times (c) Other such reliable means available to the staff at all times. This deficient practice could affect staff and up to 11 patients.

Findings include:

Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/29/18 at 9:50 a.m., 4th floor public bathrooms contained a locked door handle. Based on interview at the time of observation, the Intake Coordinator confirmed that she did not know where the key is to unlock the public bathrooms.

Based on observation and interview, the facility failed to ensure 1 of 1 Surgery Waiting room smoke barrier door was only held open by a release device complying with LSC 7.2.1.8.2 that automatically closes such doors upon activation of the fire alarm system. This deficient practice could affect staff and any occupants in the Waiting room.

Findings include:

Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/30/18 at 10:22 a.m., the Surgery Waiting room entrance smoke barrier door was propped open with a chair that prevent the door from self-closing. When the door was tested, the door self-closed, hit the frame, and left a three eights inch gap. Based on interview at the time of observation, the Director of Facilities and the Maintenance Technician #1 moved the chair and provided the door gap from the frame.

Based on record review and interview; the facility failed to install exit signage in 2 of 11 2nd floor corridors in the facility in accordance with LSC 7.10. LSC 7.10.1.2.1 exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access. This deficient practice could affect staff and up to 12 patients.

Findings include:

Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/29/18 at 11:50 a.m. then again at 11:57 a.m., the exit by patient room 269 contained four separate signs stating "STOP" with an illuminated exit sign above the door. Then again, the exit by patient room 261 contained four separate signs stating "STOP" with an illuminated exit sign above the door. Based on interview at the time of observation, the Director of Facilities and the Maintenance Technician #1 acknowledged the conflicting exit directions.

Based on observation, record review, and interview, the facility failed to maintain protection of 1 of 1 Condensation shaft. This deficient practice could affect staff and any occupants near the Front Entrance.

Findings include:

Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/30/18 at 9:09 a.m., the Condensation vertical opening shaft 1st floor door had a forty five instead of a ninety minute fire resistive tag. Based on record review at the time of observation, the Condensation shaft is two hour rated. Based on interview at the time of observation and record review, the Director of Facilities and the Maintenance Technician #1 confirmed the door was rated forty five minutes in a two hour rated fire barrier.

1. Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 21.3.4.1. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, 17.7.4.1 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 staff and at least 16 patients.

Findings include:

Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/29/18 between 10:08 a.m. and 10:31 a.m., the following was discovered:
a) a smoke detector was eighteen inches away from a ceiling vent near patient room 400
b) a smoke detector was twelve inches away from a ceiling vent near patient room 315
c) a smoke detector was twelve inches away from a ceiling vent near the Program Director's office
Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/30/18 at 10:59 a.m., the following was discovered:
d) a smoke detector was twenty inches away from a ceiling vent near 1st floor OR locker
Based on interview at the time of each observation, the Director of Facilities and the Maintenance Technician #1 acknowledged each smoke detector was located in a direct airflow or closer than 36 inches from an air supply diffuser or return air opening.

2. Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 19.3.4.1. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, 17.7.3.1.2 requires the location and spacing requirements shall be based on six factors. (2) Ceiling height. (5) Compartment ventilation. NFPA 72 17.7.3.2.1 spot-type smoke detectors shall be located on the ceiling, or, if on a sidewall, between the ceiling and 12 inches down from the ceiling to the top of the detector. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/30/18 at 11:02 a.m., the equipment room next to the Imaging Suite had a smoke detector two and a half feet from the drop ceiling. The drop ceiling was not smoke resistive because multiple gaps would allow smoke and heat to pass through. Based on interview at the time of observation, the Director of Maintenance and the Maintenance Technician #1 acknowledged each gap in the drop ceiling, provided the measurement from the smoke detector from the ceiling, and was unable to confirm if a smoke detector was above the drop ceiling.

Based on record review and interview, the facility failed to provide a complete 1 of 1 written policy for the protection of residents indicating 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 twenty four hour period in accordance with LSC, Section 9.6.1.6. This deficient practice affects all occupants.

Findings include:

Based on record review with the Facility Manager on 08/29/18 between 9:41 a.m. and 2:45 p.m., the facility provided fire watch documentation but it was incomplete. The plan failed to include contacting the Indiana State Department of Health via the Web Portal. Based on an interview at the time of record review, the Facility Manager acknowledged fire watch policy failed to include the web link for contacting the Incident Reporting System located on the Indiana State Department of Health (ISDH) Gateway.

Based on observation and interview, the facility failed to ensure a 1 of 1 complete automatic sprinkler system was installed in accordance with 21.3.5.1. NFPA 13, 2010 Edition, Standard for the Installation of Sprinkler Systems, Section 9.1.1.7, Support of Non-System Components, requires sprinkler piping or hangers shall not be used to support non-system components. This deficient practice could affect all occupants.

Findings include:

Based on observations with the Director of Facilities and the Maintenance Technician #1 on 08/29/18 between 10:15 a.m. and 2:57 p.m., the following was discovered:
a) a sprinkler pipe was supporting a conduit via wire near the patient room 300 above the drop ceiling
b) a sprinkler pipe was supporting PVC pipe via wire in the Boiler room fire barrier above the drop ceiling
c) a sprinkler pipe was supporting a conduit via wire in the 1st floor B Elevator above the drop ceiling
Based on interview at the time of each observation, the Director of Facilities and the Maintenance Technician #1 acknowledged and confirmed the sprinkler pipes were supporting non-system components.

1. Based on observation and interview, the facility failed to maintain 1 of 1 sprinkler system in accordance with 19.3.5.3. NFPA 25, 2011 Edition, 5.3.2.1 states gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/29/18 at 11:19 a.m., the sprinkler gauge in the 2nd floor B stairwell had a manufacturer date of 1988. Based on interview at the time of observation, the Director of Facilities and the Maintenance Technician #1 confirmed the date on the gauge and was unable to provide documentation to confirm the gauge was calibrated.

2. Based on record review and interview, the facility failed to maintain 1 of 1 sprinkler system in accordance with LSC 9.7.5. LSC 9.7.5 requires all automatic sprinkler systems shall be inspected and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 edition, Table 5.1.1.2 indicates the required frequency of inspection and testing. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Facility Manager on 08/29/18 between 9:41 a.m. and 2:45 p.m., the sprinkler system was inspected quarterly. No documentation was available for the monthly control valves and monthly wet system gauge inspection. Based on interview at the time of record review, the Administrator and the Director of Maintenance acknowledged the lack of documentation.

Based on record review and interview, the facility failed to provide a 1 of 1 written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out-of-service for 10 hours or more in a 24-hour period in accordance with LSC, Section 9.7.5. LSC 9.7.5 requires sprinkler impairment procedures comply with NFPA 25, 2011 Edition, the Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 15.5.2 requires nine procedures that the impairment coordinator shall follow. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Facility Manager on 08/29/18 between 9:41 a.m. and 2:45 p.m., the facility provided fire watch documentation but it was incomplete. The plan failed to include contacting the insurance company and contacting Indiana State Department of Health via the Web Portal. Based on an interview at the time of record review, the Facility Manager acknowledged fire watch policy failed to include contacting the insurance company and including the web link for contacting the Incident Reporting System located on the Indiana State Department of Health (ISDH) Gateway.

Based on observation and interview, the facility failed to ensure 1 of 1 1st floor Helipad adjacent portable fire extinguishers was installed correctly in accordance with 19.3.5.12. NFPA 10, the Standard for Portable Fire Extinguishers, 7.2.2, Procedures, requires periodic inspection or electronic monitoring of fire extinguishers shall include a check of six items. (3) Pressure gauge reading or indicator in the operable range or position. This deficient practice could affect staff and up to 1 patient.

Findings include:

Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/30/18 at 11:46 a.m., the 1st floor Helipad fire extinguisher gauge indicated the fire extinguisher was undercharged. Based on interview at the time of observation, the Director of Facilities and the Maintenance Technician #1 confirmed the fire extinguisher was undercharged.

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 4 of 10 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.3 requires smoke barriers to be constructed in accordance with LSC Section 8.5 and shall have a minimum ½ hour fire resistive rating. This deficient practice could affect staff and up to 20 patients.

Findings include:

Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/29/18 between 9:56 a.m. and 10:15 a.m., the following unsealed penetrations were discovered:
a) a half inch gap around wires in the 4th floor smoke barrier above the drop ceiling
b) a half inch gap around wires in the smoke barrier near patient room 300

Based on observations with the Director of Facilities and the Maintenance Technician #1 on 08/30/18 between 9:05 a.m. and 10:42 a.m., the following unsealed penetrations were discovered:
a) a one inch by two inch gap and a one and one half inch by three inch gap was in the Health Information smoke barrier above the drop ceiling
b) a half inch gap around a wire in the Surgery Waiting smoke barrier above the drop ceiling

Based on interview at the time of each observation, the Director of Facilities and the Maintenance Technician #1 acknowledged each aforementioned condition and provided the measurements.

Based on observation and interview, the facility failed to ensure 1 of 1 electrical junction boxes observed was maintained in a safe operating condition in accordance with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 2011 Edition. NFPA 70, 2011 Edition, Article 314.28(C) requires all pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. This deficient practice could affect staff and up to 12 patients.

Findings include:

Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/29/18 at 11:58 a.m., there was exposed wiring in an electrical box without a cover above the drop ceiling near the patient room 261 smoke barrier. Based on interview at the time of observation, the Maintenance Supervisor acknowledged the exposed wiring.

Based on observation and interview, the facility failed to ensure 7 of 7 candles was maintained in accordance with 19.7.5.6(4). LSC 19.7.5.6(4) prohibits combustible decorations unless an exception was met. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/29/18 at 10:30 a.m. then again at 12:01 p.m., the 3rd floor Program Director's office contained two separate candles with wicks. Then again, five candles with wicks were in the OB Nurse's Managers office. Based on interview at the time of observation, the Director of Facilities and the Maintenance Technician #1 confirmed a wick was in each candle.

Based on observation and interview, the facility failed to ensure there were battery-powered lighting for 1 of 4 1st floor Operating Rooms using general anesthesia. NFPA 99 2012 edition 6.3.2.2.11.1 states one or more battery-powered lights shall be provide within locations where deep sedation and general anesthesia is administered. 6.3.2.2.11.2 The lighting level of each unit shall be sufficient to terminate procedures intended to be performed within the operating room. This deficient practice could affect staff and one patients.

Findings include:

Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/30/18 at 10:15 a.m., 1st floor operating room #3 did not have battery operated emergency lighting. Based on interview at the time of observation, the Director of Facilities and the Maintenance Technician #1 acknowledged staff's confirmation that anesthesia is used and confirmed no battery operated emergency light is installed in the 1st floor operating room #3.

Based on observation and interview, the facility failed to ensure 1 of 1 multiplug and 4 of 4 flexible cords were not used as a substitute for fixed wiring according to 9.1.2. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice affects staff and up to 4 patients.

Findings include:

Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/29/18 between 10:43 a.m. and 2:20 p.m., the following was discovered:
a) a surge protector was powering a coffee pot and refrigerator in the Social Worker's office
b) a surge protector was powering a microwave, coffee pot, and a toaster in the OB Break room
c) a surge protector was powering a coffee pot in the Maintenance Shop

Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/30/18 between 9:21 a.m. and 10:48 a.m., the following was discovered:
d) a multiplug adapter was powering monitoring equipment in Sleep Lab #2
e) a surge protector was powering a refrigerator and a microwave in the ICU Break room
Based on interview at the time of each observation, the Director of Facilities and the Maintenance Technician #1 confirmed the surge protector was powering each aforementioned high amperage device.

Based on observation and interview, the facility failed to ensure 1 of 1 exterior oxygen transfill shed was protected in accordance with 11.2.3.2. 2012 NFPA 99 11.3.2.3 requires oxidizing gases such as oxygen and nitrous oxide shall be separated 5 feet from combustibles or materials. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/29/18 at 3:03 p.m., the exterior oxygen transfill shed contained liquid oxygen stored within 5 feet of wooden support beams. Based on interview at the time of observation, the Director of Facilities and the Maintenance Technician #1 confirmed liquid oxygen containers were stored within five feet of the wooden beams that hold up the shed.

Based on observation and interview, the facility failed to ensure 1 of 1 exterior oxygen transfill shed was protected in accordance with 9.3.7. NFPA 99, Section 9.3.7.5 states indoor storage or manifold areas and storage or manifold
buildings for medical gases and cryogenic fluids shall be provided with natural ventilation or mechanical exhaust ventilation in accordance with Sections 9.3.7.5.1 through 9.3.7.8. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Facilities and the Maintenance Technician #1 on 08/29/18 at 3:03 p.m., the exterior oxygen transfill shed did not have mechanical or natural ventilation provided. Based on interview at the time of observation, the Director of Facilities and the Maintenance Technician #1 confirmed the oxygen transfill shed does not have a natural or mechanical ventilation.