HospitalInspections.org

1. Based on observation and interview, the hospital failed to ensure continuity of exterior egress lighting for 1 of 14 exits. This deficient practice could affect any patients, staff and visitors using the "old" doctor's exit at the main hospital.

Findings include:

Based on observation during a tour of the main hospital with the maintenance supervisor and plant manager on 04/20/10 at 2:50 p.m., the exit discharge for the "old" doctor's exit at the hospital was equipped with one light fixture with a single bulb. The maintenance supervisor and plant manager stated at the time of the observation, they would correct the exterior lighting for the "old" doctor's exit.

2. Based on observation and interview, the facility failed to ensure continuity of exterior egress lighting for 1 of 4 exits at the Rehabilitation Center in Nappanee. LSC, Chapter 38.2.8 requires means of egress shall be illuminated in accordance with Section 7.8. LSC 7.8.1.4 requires the illumination to be arranged so the failure of any single lighting unit will not result in an illumination of less than 0.2 foot candle in any designated area. This deficient practice could affect any patients, staff and visitors using the side exit from the Center.

Findings include:

Based on observation during a tour of the Rehabilitation Center at Nappanee with the maintenance supervisor on 04/21/10 at 12:15 p.m., the exit discharge for side exit was equipped with one light fixture with a single bulb. The maintenance supervisor stated at the time of the observation, he would correct the exterior lighting for the exit at Nappanee.

1. Based on record review and interview, the hospital failed to ensure fire drills were conducted at various times and under various conditions for each shift for 4 of 4 quarters at the main hospital. This deficient practice could effect all patients, staff and visitors at the main hospital in the event of an emergency.

Findings include:

Based on review of the hospital's Fire Drill records and interview on 04/19/10 at 2:05 p.m. with the maintenance supervisor and plant manager, the first shift fire drills were conducted between the 10:00 a.m. and 11:00 a.m. hour for the second and fourth quarters of 2009 and the first quarter of 2010. The second shift fire drills were conducted within the 10:20 p.m. hour for the second, third and fourth quarters of 2009 and the first quarter of 2010. The third shift fire drills were conducted within the 3:30 a.m. hour for the second, third and fourth quarters of 2009 and the first quarter of 2010. The maintenance supervisor and plant manager stated at the time of the record review, they were not aware of the problem.

2. Based on record review and interview, the hospital failed to provide suitable procedures to ensure the participation of all persons subject to routine fire drills participated on each shift for 12 of 12 months at the main hospital. LSC 4.7.2 requires the facility to have suitable procedures to ensure all persons subject to the drill participate. This deficient practice could effect all patients, staff and visitors at the hospital in the event of an emergency.

Findings include:

Based on review of the hospital's Fire Drill records and interview on 04/20/10 at 11:25 a.m. with the maintenance supervisor and plant manager, the hospital had no evidence or documentation that personnel participated in routine fire drills. The maintenance supervisor and plant manager stated at the time of observation, they were not aware the facility had no evidence of hospital personnel participating in fire drills. They indicated documentation may be generated by the Human Resources Department.

Based on observation and interview, the hospital failed to ensure 1 of 4 fire alarm control panels located in an area not continuously occupied was provided with automatic smoke detection to ensure notification of a fire at that location before it is incapacitated by fire. LSC 9.6.2.10 refers to NFPA 72, the National Fire Alarm Code. NFPA 72 at 1-5.6 requires an automatic smoke detector be provided at the location of each fire alarm control unit which is not located in an area continuously occupied to provide notification of a fire in that location. This deficient practice affects all patients, staff and visitors in the event of an emergency.

Findings include:

Based on observations on 04/20/10 at 3:20 p.m. with the maintenance supervisor and plant manager, the fire alarm control panel for the main hospital was located in the the mechanical room and was not electronically supervised by a smoke detector.

1. Based on record review, observation and interview; the main hospital failed to ensure a written record of weekly inspections of the starting batteries for the generator was maintained for 3 of 52 weeks for 1 of 3 generator sets. Chapter 3-4.4.1.3 of NFPA 99 requires storage batteries used in connection with essential electrical systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer's specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects. Furthermore, NFPA 110, 6-3.6 requires storage batteries, including electrolyte levels, be inspected at intervals of not more than 7 days. Chapter 3-5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of the generator logs with the maintenance supervisor and plant manager on 04/19/10 at 2:35 p.m., the main hospital exceeded the seven day requirement for the weeks of 01/06/10 to 01/15/10, 01/20/10 to 01/28/10 and 02/16/10 to 02/24/10. The maintenance supervisor and plant manager stated at the time of review, they did not understand the seven day requirement.

2. Based on record review, observation and interview; the Center for Rehabilitation at Nappanee failed to ensure a written record of weekly inspections of the starting batteries for the generator was maintained for 52 of 52 weeks. Chapter 38.2.1.1 requires all means of egress be in accordance with Chapter 7. LSC 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 99 requires storage batteries used in connection with essential electrical systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer's specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects. Furthermore, NFPA 110, 6-3.6 requires storage batteries, including electrolyte levels, be inspected at intervals of not more than 7 days. Chapter 3-5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of the generator logs with the maintenance supervisor on 04/19/10 at 2:35 p.m., the Rehabilitation Center at Nappanee did not document or maintain records of generator battery inspections every seven days. The maintenance supervisor stated at the time of observation on 04/20/10 at 12:40 p.m., he did not understand the seven day inspection requirement and was not aware he was required to maintain the generator documentation.

Based on observation and interview, the main hospital failed to ensure flexible cords such as extension cords were not used as a substitute for fixed wiring in 1 of 1 hospital laboratories. LSC 19.5.1 requires utilities to comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 1999 Edition. NFPA 70, Article 400-8 requires, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could affect all occupants in the Goshen General Hospital Lab.

Findings include:

Based on observation during a tour of the main hospital lab with the maintenance supervisor and plant manager on 04/20/10 at 2:55 p.m., an extension cord was plugged into a specimen refrigerator which was plugged into the wall. The maintenance supervisor agreed at the time of the observation, the extension cord should not have been used and will be hard wired.

Based on record review and interview, the main hospital failed to provide a complete written policy containing procedures to be followed to protect 73 of 73 patients in the event the automatic sprinkler system has to be placed out of service for 4 hours or more in a 24 hour period in accordance with LSC, Section 9.7.6.1. LSC, 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, Standard for Inspection, Testing and Maintenance of Water Based Fire Protection Systems. NFPA 25, 11-5(d) requires the local fire department to be notified of a sprinkler impairment and 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also to be notified. This deficient practice could affect all occupants in the facility including patients, staff and visitors.

Findings include:

Based on review of the hospital's policy and procedure book with the maintenance supervisor and plant manager on 04/20/10 at 3:45 p.m., the fire watch procedure for an out of service automatic sprinkler system was not complete. The policy and procedure lacked the requirement to train and designate staff assigned to complete fire watch rounds and to document each round every 15 minutes. The procedure also lacked the required telephone numbers for the Indiana State Department of Health (317-233-5359) and the local fire department. The maintenance supervisor and plant manager stated at the time of review, they had no other policy or procedure documentation available to review.

Based on record review and interview the main hospital 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 to protect 73 of 73 patient, in accordance with LSC, Section 9.6.1.8. LSC, 19.7.1.1 requires every health care occupancy to have in effect and available to all supervisory personnel a plan for the protection of all persons. All employees shall periodically be instructed and kept informed with respect to their duties under the plan. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 19.7.2.2 requires all fire safety plans to provide for the use of alarms, the transmission of the alarm to the fire department and response to alarms. 19.7.2.3 requires health care personnel to be instructed in the use of a code phrase to assure transmission of the alarm during a malfunction of the building fire alarm system. This deficient practice could affect all patients, staff and visitors. .

Findings include:

Based on review of the hospital's policy and procedure book with the maintenance supervisor and plant manager on 04/20/10 at 3:45 p.m., the fire watch procedure for an out of service automatic alarm system was not complete. The policy and procedure lacked the requirement to train and designate staff assigned to complete fire watch rounds and to document each round every 15 minutes. The procedure also lacked the required telephone numbers for the Indiana State Department of Health (317-233-5359) and the local fire department. The maintenance supervisor and plant manager stated at the time of review, they had no other policy or procedure documentation available to review.

Based on observation and interview, the main hospital failed to ensure a at least 16 of 16 alcohol hand sanitizing dispensers in the PCU patient rooms and in the area of the Emergency Room (ER) were not installed over or adjacent to ignition sources such as electrical switches and outlets which may arc during normal use creating an ignition source. LSC 19.1.1.3 requires all health care facilities to be designed, constructed, maintained and operated to minimize the possibility of a fire emergency. This deficient practice could affect all patients, staff and visitors in the hospital PCU and ER.

Findings include:

Based on observations of the hospital on 04/20/10 between 2:15 p.m. and 4:10 p.m. with the maintenance supervisor and plant manager, the hand sanitizing dispensers in each of the patient's rooms on the third floor PCU and within the ER had the dispensers mounted six inches, or less, from the light switches and an electric door opener. The maintenance supervisor and plant manager stated at the time of the observations, they were not aware of the requirement.

1. Based on observation and interview, the hospital failed to ensure continuity of exterior egress lighting for 1 of 14 exits. This deficient practice could affect any patients, staff and visitors using the "old" doctor's exit at the main hospital.

Findings include:

Based on observation during a tour of the main hospital with the maintenance supervisor and plant manager on 04/20/10 at 2:50 p.m., the exit discharge for the "old" doctor's exit at the hospital was equipped with one light fixture with a single bulb. The maintenance supervisor and plant manager stated at the time of the observation, they would correct the exterior lighting for the "old" doctor's exit.

2. Based on observation and interview, the facility failed to ensure continuity of exterior egress lighting for 1 of 4 exits at the Rehabilitation Center in Nappanee. LSC, Chapter 38.2.8 requires means of egress shall be illuminated in accordance with Section 7.8. LSC 7.8.1.4 requires the illumination to be arranged so the failure of any single lighting unit will not result in an illumination of less than 0.2 foot candle in any designated area. This deficient practice could affect any patients, staff and visitors using the side exit from the Center.

Findings include:

Based on observation during a tour of the Rehabilitation Center at Nappanee with the maintenance supervisor on 04/21/10 at 12:15 p.m., the exit discharge for side exit was equipped with one light fixture with a single bulb. The maintenance supervisor stated at the time of the observation, he would correct the exterior lighting for the exit at Nappanee.

1. Based on record review and interview, the hospital failed to ensure fire drills were conducted at various times and under various conditions for each shift for 4 of 4 quarters at the main hospital. This deficient practice could effect all patients, staff and visitors at the main hospital in the event of an emergency.

Findings include:

Based on review of the hospital's Fire Drill records and interview on 04/19/10 at 2:05 p.m. with the maintenance supervisor and plant manager, the first shift fire drills were conducted between the 10:00 a.m. and 11:00 a.m. hour for the second and fourth quarters of 2009 and the first quarter of 2010. The second shift fire drills were conducted within the 10:20 p.m. hour for the second, third and fourth quarters of 2009 and the first quarter of 2010. The third shift fire drills were conducted within the 3:30 a.m. hour for the second, third and fourth quarters of 2009 and the first quarter of 2010. The maintenance supervisor and plant manager stated at the time of the record review, they were not aware of the problem.

2. Based on record review and interview, the hospital failed to provide suitable procedures to ensure the participation of all persons subject to routine fire drills participated on each shift for 12 of 12 months at the main hospital. LSC 4.7.2 requires the facility to have suitable procedures to ensure all persons subject to the drill participate. This deficient practice could effect all patients, staff and visitors at the hospital in the event of an emergency.

Findings include:

Based on review of the hospital's Fire Drill records and interview on 04/20/10 at 11:25 a.m. with the maintenance supervisor and plant manager, the hospital had no evidence or documentation that personnel participated in routine fire drills. The maintenance supervisor and plant manager stated at the time of observation, they were not aware the facility had no evidence of hospital personnel participating in fire drills. They indicated documentation may be generated by the Human Resources Department.

Based on observation and interview, the hospital failed to ensure 1 of 4 fire alarm control panels located in an area not continuously occupied was provided with automatic smoke detection to ensure notification of a fire at that location before it is incapacitated by fire. LSC 9.6.2.10 refers to NFPA 72, the National Fire Alarm Code. NFPA 72 at 1-5.6 requires an automatic smoke detector be provided at the location of each fire alarm control unit which is not located in an area continuously occupied to provide notification of a fire in that location. This deficient practice affects all patients, staff and visitors in the event of an emergency.

Findings include:

Based on observations on 04/20/10 at 3:20 p.m. with the maintenance supervisor and plant manager, the fire alarm control panel for the main hospital was located in the the mechanical room and was not electronically supervised by a smoke detector.

1. Based on record review, observation and interview; the main hospital failed to ensure a written record of weekly inspections of the starting batteries for the generator was maintained for 3 of 52 weeks for 1 of 3 generator sets. Chapter 3-4.4.1.3 of NFPA 99 requires storage batteries used in connection with essential electrical systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer's specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects. Furthermore, NFPA 110, 6-3.6 requires storage batteries, including electrolyte levels, be inspected at intervals of not more than 7 days. Chapter 3-5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of the generator logs with the maintenance supervisor and plant manager on 04/19/10 at 2:35 p.m., the main hospital exceeded the seven day requirement for the weeks of 01/06/10 to 01/15/10, 01/20/10 to 01/28/10 and 02/16/10 to 02/24/10. The maintenance supervisor and plant manager stated at the time of review, they did not understand the seven day requirement.

2. Based on record review, observation and interview; the Center for Rehabilitation at Nappanee failed to ensure a written record of weekly inspections of the starting batteries for the generator was maintained for 52 of 52 weeks. Chapter 38.2.1.1 requires all means of egress be in accordance with Chapter 7. LSC 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 99 requires storage batteries used in connection with essential electrical systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer's specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects. Furthermore, NFPA 110, 6-3.6 requires storage batteries, including electrolyte levels, be inspected at intervals of not more than 7 days. Chapter 3-5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of the generator logs with the maintenance supervisor on 04/19/10 at 2:35 p.m., the Rehabilitation Center at Nappanee did not document or maintain records of generator battery inspections every seven days. The maintenance supervisor stated at the time of observation on 04/20/10 at 12:40 p.m., he did not understand the seven day inspection requirement and was not aware he was required to maintain the generator documentation.

Based on observation and interview, the main hospital failed to ensure flexible cords such as extension cords were not used as a substitute for fixed wiring in 1 of 1 hospital laboratories. LSC 19.5.1 requires utilities to comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 1999 Edition. NFPA 70, Article 400-8 requires, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could affect all occupants in the Goshen General Hospital Lab.

Findings include:

Based on observation during a tour of the main hospital lab with the maintenance supervisor and plant manager on 04/20/10 at 2:55 p.m., an extension cord was plugged into a specimen refrigerator which was plugged into the wall. The maintenance supervisor agreed at the time of the observation, the extension cord should not have been used and will be hard wired.

Based on record review and interview, the main hospital failed to provide a complete written policy containing procedures to be followed to protect 73 of 73 patients in the event the automatic sprinkler system has to be placed out of service for 4 hours or more in a 24 hour period in accordance with LSC, Section 9.7.6.1. LSC, 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, Standard for Inspection, Testing and Maintenance of Water Based Fire Protection Systems. NFPA 25, 11-5(d) requires the local fire department to be notified of a sprinkler impairment and 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also to be notified. This deficient practice could affect all occupants in the facility including patients, staff and visitors.

Findings include:

Based on review of the hospital's policy and procedure book with the maintenance supervisor and plant manager on 04/20/10 at 3:45 p.m., the fire watch procedure for an out of service automatic sprinkler system was not complete. The policy and procedure lacked the requirement to train and designate staff assigned to complete fire watch rounds and to document each round every 15 minutes. The procedure also lacked the required telephone numbers for the Indiana State Department of Health (317-233-5359) and the local fire department. The maintenance supervisor and plant manager stated at the time of review, they had no other policy or procedure documentation available to review.

Based on record review and interview the main hospital 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 to protect 73 of 73 patient, in accordance with LSC, Section 9.6.1.8. LSC, 19.7.1.1 requires every health care occupancy to have in effect and available to all supervisory personnel a plan for the protection of all persons. All employees shall periodically be instructed and kept informed with respect to their duties under the plan. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 19.7.2.2 requires all fire safety plans to provide for the use of alarms, the transmission of the alarm to the fire department and response to alarms. 19.7.2.3 requires health care personnel to be instructed in the use of a code phrase to assure transmission of the alarm during a malfunction of the building fire alarm system. This deficient practice could affect all patients, staff and visitors. .

Findings include:

Based on review of the hospital's policy and procedure book with the maintenance supervisor and plant manager on 04/20/10 at 3:45 p.m., the fire watch procedure for an out of service automatic alarm system was not complete. The policy and procedure lacked the requirement to train and designate staff assigned to complete fire watch rounds and to document each round every 15 minutes. The procedure also lacked the required telephone numbers for the Indiana State Department of Health (317-233-5359) and the local fire department. The maintenance supervisor and plant manager stated at the time of review, they had no other policy or procedure documentation available to review.