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Based on record review and interview, the facility failed to ensure the building construction type was a permitted type as listed in Table 19.1.6.2. Table 19.1.6.2 requires a building, four or more stories in height, to be Type II (222), Type I (332) or Type I (443). This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review with the Director of Engineering Services on 03/29/16 between 8:34 a.m. and 11:24 a.m., part of the Elkhart General Hospital main building was constructed of type II (000) construction. Based on interview at the time of record review, the Director of Engineering Services confirmed part of the hospital was constructed at II (000) and was aware of the aforementioned condition. He further explained that the floor/ceiling rating was constructed of two hours but was unable to provide documentation.

1. Based on observation, the facility failed to ensure 2 of 8 office doors and 1 of 1 triage doors on the fourth floor west protecting corridor openings did not have an impediment to the closing of the doors. This deficient practice could affect approximately 40 patients on the west wing fourth floor.

Findings include:

Based on observation during the tour of the facility with the Manager of Plant Operations on 03/30/16 between 11:15 a.m. and 12:15 p.m., the corridor doors to the Director of Surgery office, the Executive Director of Surgery office, and triage were propped open with a wedge pushed under the door. Based on interview at the time of observation, the Manager of Plant Operations acknowledged that the door wedges were an impediment to closing the doors.

2. Based on observation and interview, the facility failed to ensure 2 of 2 MRI Control Room and 1 of 2 Private Dining Room corridor doors closed and latched into the door frame. This deficient practice could affect staff and up to 2 patients.

Findings include:

Based on observation and interview on 03/30/16 at 11:48 a.m. then again at 2:10 p.m., the Director of Engineering Services acknowledged the two separate corridor doors to the MRI Control Room had a wooden door stop that prevented the door from closing and latching into the door frame. Then again, one of the corridor doors to the Private Dining Room did not contain latching hardware and was unable to latch into the frame.

Based on observation and interview, the facility failed to ensure 1 of 4 of basement stair door assemblies in a vertical opening were of an approved type with appropriate fire protection rating. This deficient practice was not in a patient care area but could affect all staff in the basement.

Finding include:

Based on observation during a tour of the facility with the Manager of Plant Operations on 03/30/16 at 09:30 a.m., the fire rating for the basement stair door #6 protecting a vertical opening could not be determined. Upon inspection of the door, no label could be found to determine the fire rating of the door. Based on interview at the time of observation, the Manager of Plant Operations stated there was no documentation of the door's fire rating and a contractor was scheduled on 04-01-2016 to provide documentation for the door.

1. Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 1 of 1 ceiling barrier and 1 of 1 North PACU smoke barrier wall was 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 8-3. 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 staff and at least 12 patients.

Findings include:

Based on observations with the Director of Engineering Services on 03/29/16 at 2:52 p.m., two separate half inch and one single two inch ceiling penetrations was in the Data Closet Room 2400.
Based on observations with the Director of Engineering Services on 03/30/16 between 10:12 a.m. and 4:03 p.m., the following penetrations were discovered:
a) one eighth inch ceiling penetrations across from the Medical Records office
b) nine separate ceiling penetrations around conduit ranging from an eighth of an inch to an inch in Room 1837A.
c) three of twelve ceiling tiles were missing next to the Security office Room 1837A.
d) a three foot by one foot piece of drywall was removed from the PACU North smoke barrier above the drop ceiling.
Based on interview at the time of observation, the Director of Engineering Services acknowledged each aforementioned condition and provided the measurements.

2. Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 1 of 1 smoke barrier by Woman's Health and 1 of 1 smoke barrier by OBG/YN Associates was 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 8-3. 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 staff and up to 22 patients.

Findings include:

Based on observations with the Manager of Plant Operations on 03/30/16 at 2:50 p.m. then again at 2:51 p.m., the smoke barrier by Woman's Health Room 1965 there was a three inch unsealed penetrations around wires above the drop ceiling. Then again, the smoke barrier near the OBG/YN Associates room were two separate one inch unsealed penetrations above the drop ceiling. Based on interview at the time of each observation, the Manager of Plant Operations acknowledged each aforementioned condition and provided the measurements.

Based on observation and interview, the facility failed to ensure 1 of 3 sets of 4th floor smoke barrier doors would close to form a smoke resistant barrier. This deficient practice could affect staff and at least 12 patients.

Findings include:

Based on observation with the Director of Engineering Services on 03/29/16 at 12:36 p.m., both smoke barrier doors by patient room 4114 caught on the floor when released and failed to close. Based on interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition.

1. Based on observation and interview, the facility failed to ensure corridor doors to 2 of 15 hazardous area in the basement and 1 of 9 hazardous area on first floor west wing, was provided with a self-closing device causing the doors to automatically close and latch into the door frame. This deficient practice could affect up to 90 patients in the west wing of the hospital and all staff in the basement.

Findings include:

Based on an observation during a tour of the facility with the Manager of Plant Operations on 03/30/15 Between 09:00 a.m. and 11:30 a.m., the following doors to hazardous areas lacked a self-closer and/or failed to latch into the frame:
a. the corridor door leading into the basement print shop, which was greater than 50 square feet and contained 400 plus boxes containing supplies, was not equipped with a self-closing device.
b. the corridor door leading into the basement grease trap room, which was greater than 50 square feet and contained 50 plus boxes and a 10 gallon grease trap, was not equipped with a self-closing device.
d. the corridor door to the soiled utility room by the Brest Center, containing barrels of trash and soiled linens, was equipped with a self-closing device but failed to latch into the frame.
Based on interview, this was acknowledged by the Manager of Plant Operations at the time of observations.

2. Based on observation and interview, the facility failed to ensure the corridor door to 1 of 1 6th Floor North PCU Nurse's station, 1 of 1 4th floor Soiled Utility room 4410B, 1 of 1 Patient Room 2409, and 1 of 1 Serving Area containing more than 36 gallons of hazardous soiled linen and or trash in a 64 square foot area, a hazardous area, was not stored in the corridor or provided with self-closer and would latch into the frame. This deficient practice could affect staff and up to least 28 patients.

Findings include:

Based on observation with the Director of Engineering Services on 03/29/16 between 11:50 a.m. and 3:06 p.m., the following was discovered:
a) four separate trash containers totaling 53 gallons in the 6th Floor North PCU Nurse's station
b) two separate soiled utility containers totaling 58 gallons in the 4th floor Soiled Utility room 4410B lacked self-closing device
c) two separate soiled utility containers totaling 60 gallons in the corridor near Patient Room 2409
Based on observation with the Maintenance Supervisor and Maintenance Assistant on 1/7/16 at 9:04 a.m., the following was discovered:
d) three separate trash containers totaling 132 gallons in the Serving Area
Based on interview at the time of each observation, the Director of Engineering Services acknowledged each aforementioned condition.

3. Based on observation and interview, the facility failed to ensure the corridor door to 1 of 1 Room 4115 containing combustible materials greater than 50 square feet, a hazardous area, was provided with self-closer and would latch into the frame. This deficient practice could affect staff and up to 14 patients.

Findings include:

Based on observation with the Director of Engineering Services on 03/30/16 at 12:33 p.m., Room 4115 contained ten wooden chairs, one mattress, and twenty nine large cardboard boxes. The corridor door was not provided with a self-closing device. Based on interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition.

4. Based on observation and interview, the facility failed to ensure the corridor doors to 1 of 1 room kitchen, a hazardous area, would latch into the frame. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Engineering Services on 03/30/16 at 10:42 a.m. then again at 10:46 a.m., one of the kitchen doors self-closed but failed to latch into the frame. Then again, the tray return area was open to the kitchen. A two foot by three foot hole was in the wall for lunch trays to be transported. Based on interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition and provided the measurements.

Based on observation and interview, the facility failed to ensure exit access was arranged so 1 of 3 exits were readily accessible at all times in accordance with LSC Section 7.1. LSC Section 7.1 requires the means of egress for existing buildings shall comply with Chapter 7. LSC Section 7.7.1 requires all exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. In addition to providing the required width to allow all occupants safe access to a public way, such access also needs to meet the requirements with respect to maintaining the means of egress free of obstructions that would prevent its use, such as snow and the need for its removal in some climates or soft ground during heavy periods of rain. This deficient practice could affects staff, visitors, and at least 3 patients.
Findings include:
Based on observation with the Director of Engineering Services on 03/30/16 at 9:37 a.m., Stair #9 exit discharged into grass. Based on interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition and confirmed that path was considered an exit.

Based on observation and interview, the facility failed to ensure 2 of 7 3rd floor, 1 of 4 2nd floor, and 1 of 4 1st floor fire door sets were arranged to automatically close and latch. LSC 19.2.2.5 requires horizontal exits to be in accordance with 7.2.4 and 7.2.4.3.8 requires fire doors to be self-closing or automatic closing in accordance with 7.2.1.8. In addition NFPA 80, Standard for Fire Doors and Windows at 2-1.4.1 requires all closing mechanisms shall be adjusted to overcome fire resistance of the latch mechanism so that positive latching is achieved on each door operation. These deficient practices could affect staff and up to 54 patients.

Findings include:

Based on observation with the Director of Engineering Services on 03/29/16 at 2:06 p.m. to 2:35 p.m., the following fire barriers failed to latch into the frame when tested:
a) 3rd floor North East Building/ Critical Care
b) 3rd floor East/ West fire doors near room 3742
c) 2nd floor North East by H Elevators

Based on observation with the Director of Engineering Services on 03/30/16 at 12:00 p.m., the 1st floor fire doors near Elevator K failed to latch when tested. Based on interview at the time of each observation, the Director of Engineering Services acknowledged the aforementioned conditions and confirmed the set of doors were fire doors.

Based on record review and interview; the facility failed to ensure 19 of 19 battery operated emergency lights in the facility was maintained in accordance with LSC 7.9. LSC 7.9.3, Periodic Testing of Emergency Lighting Equipment, requires a functional test to be conducted for 30 seconds at 30 day intervals and an annual test to be conducted on every required battery powered emergency lighting system for not less than a 1 ½ hour 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 staff only.

Findings include:

Based on record review with the Director of Engineering Services on 03/29/16 at 2:39 p.m., the battery operated emergency documentation indicated not all the lights received a monthly test on January 2016 and September 2015. January 2016 indicated "unable to complete due to time" and September 2015 indicated "unable to complete." Based on interview at the time of record review, the Director of Engineering Services acknowledged the aforementioned condition.

Based on record review and interview, the facility failed to provide a written plan that addressed all components in 1 of 1 written fire plans. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to the fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
This deficient practice could affect all occupants.

Findings include:

Based on a record review with the Director of Engineering Services on 03/30/16 at 9:28 a.m., the facility had a written fire policy that horizontal evacuation would be performed by crossing a smoke barrier. However, site plans showed there were separation doors on the third floor that was not part of a complete smoke or fire barrier which could cause staff to evacuate residents to a different part of the same smoke compartment and not to an adjacent compartment in the event of a fire. Based on interview during record review, the Director of Engineering Services acknowledged the aforementioned condition and confirmed the site plans indicate separation doors near patient room 3111 were not part of a complete barrier.

Based on observation and interview, the facility failed to ensure 1 of 1 smoke detector near Classroom 2 was not installed where air flow would adversely affect the operation. 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 staff only.

Findings include:

Based on observation with the Director of Engineering Services on 03/30/16 at 3:28 p.m., a smoke detector was located twenty four inches away from an HVAC supply. Based on interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition and provided the measurement.

Based on record review and interview, the facility failed to repair system defects and malfunctions indicated on 1 of 1 fire alarm report. NFPA 72, National Fire Alarm Code, 7-1.1.2 indicates that system defects and malfunctions shall be corrected. This deficient practice could affect staff only.

Findings include:

Based on record review on 03/30/16 between 3:23 p.m. and 3:25 p.m., the annual fire alarm report from ESCO Communications Incorporated indicated the following failed tests:
a) "2nd AHU 521 fan shutdown"
b) "Basement West Wing Rm 926 above Water Fountain 12ft LDR"
c) "Basement West Wing Inside Room 908 smoke detector"
Based on interview at the time or record review, the Director of Engineering Services acknowledged the aforementioned condition.

1. Based on observation and interview, the facility failed to ensure sprinkler coverage in 1 of 1 Stairwell #1 and 1 of 1 Stair #2 was installed in accordance with NFPA 13, 1999 Edition, Installation of Sprinkler Systems, 5-13.3.2 states in noncombustible stair shafts with noncombustible stairs, sprinklers shall be installed at the top of shaft and under the first landing above the bottom of the shaft. This deficient practice could affect staff and up to 185 patients.

Findings include

Based on observation with the Director of Engineering Services on 03/29/16 at 11:44 a.m. then again at 11:59 a.m., stairwell #1 lacked sprinkler coverage at the top of the stairwell. Then again, stairwell #2 lacked sprinkler coverage at the top of the stairwell. Based on interview at the time of each observation, the Director of Engineering Services acknowledged the aforementioned condition.

2. Based on observation and interview, the facility failed to ensure 1 of 5 Radiology office sprinkler heads was installed in accordance with NFPA 13, 1999 Edition, Installation of Sprinkler Systems, 5-3.1.5.2 states when existing light hazard systems are converted to use quick response or residential sprinklers, all sprinklers in a smoke compartment shall be changed. This deficient practice could affect staff up to 5 patients.

Findings include:

Based on observation with the Director of Engineering Services on 03/30/16 at 11:28 a.m., the Radiology office had a mixture of quick response sprinkler heads with the thin glass rod and standard response sprinkler heads with the thick glass rods. Based on an interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition.

3. Based on observation and interview, the facility failed to ensure the spray pattern for 1 of 1 sprinklers in the 5th floor North East Men's Bathroom was unobstructed. NFPA 25, 1998 Edition Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Section 2-2.1.2 states unacceptable obstructions to spray patterns shall be corrected. NFPA 13, 1999 Edition Standard for the Installation of Sprinkler Systems, Table 5-6.5.1.2 states that distance between a sprinkler head an obstruction less than 1 foot away cannot be lower than the sprinkler head deflector. This deficient practice could affect staff and up to 1 patient.

Findings include:

Based on observation with the Director of Engineering Services on 03/29/16 at 12:14 p.m., the spray pattern for the one sprinkler head in 5th floor North East Men's Bathroom was obstructed by a ceiling light. Measurements showed the sprinkler head was 4 inches away from the ceiling light. The ceiling light were measured to be 1 inches lower than the sprinkler head deflector. Based on interview at the time of observation, the Director of Engineering Services acknowledged the abovementioned condition and provided the measurements.

4. Based on observation and interview, the facility failed to ensure that a complete automatic sprinkler system was provided for 1 of 1 canopies in accordance with NFPA 13, Standard for Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. NFPA 13-1999 Edition, Section 5-13.8.1 requires sprinklers shall be installed under exterior roofs or combustible canopies exceeding 4 ft. in width. This deficient practice can affect all patients using the in OB/GYN offices.

Findings include:

Based on observation during a tour of the facility with the Manager of Plant Operations on 03/30/16 at 11:10 a.m., there was an un-sprinkled canvas canopy attached to the building near the OB/GYN entrance. The canvas canopy extends out 20 feet from the building. Based on interview at the time of observation, the Manager of Plant Operations acknowledge that the canopy was attached to the building, provide the measurements of the canopy, and stated there was no documentation to confirm the canvas canopy was inherently fire resistant.

3.1-19(b)
5. Based on observation, record review, and interview, the facility failed to ensure complete sprinkler coverage in 1 of 1 Stairwell #1 and 1 of 1 Mechanical Room 1723 was installed in accordance with NFPA 13, 1999 Edition, Installation of Sprinkler Systems, 1-6.1 state a building where protected by an automatic sprinkler system, shall be provided with sprinkler in all areas. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Engineering Services on 03/30/15 at 12:33 p.m., there was no sprinkler coverage in the Mechanical Room 1723. Based on record review, the site plans failed to indicate a construction rating. Based on interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition.

1. Based on observation and interview, the facility failed to ensure 1 of 1 sprinkler heads in 2nd floor Stairwell #9 was maintained. This deficient practice could affect staff and at least 36 patients.

Findings include:

Based on observations the Director of Engineering Services on 03/29/16 at 3:01 p.m., the 2nd floor Stairwell #9 was missing one escutcheon. Based on interview at the time of observation, the Director of Engineering Services acknowledged the missing escutcheon at the time of each observation.

2. Based on observation and interview, the facility failed to replace 1 of 2 painted sprinkler heads in the Staff Lounge Room 2400. LSC 33.2.3.5.2 refers to LSC section 9.7. 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, 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 staff only.

Findings include:

Based on observation with the Director of Engineering Services on 03/29/16 at 2:54 p.m., one recessed sprinkler head cover was covered in paint in the Staff Lounge Room 2400. Based on interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to ensure 1 of 1 Rehabilitation Nurse's station portable fire extinguishers were installed correctly. NFPA 10, the Standard for Portable Fire Extinguishers, Chapter 1, 1-6.10 requires the top of portable fire extinguishers weighing 40 pounds or less should be no more than five feet (60 inches) above the floor and those weighing more than 40 pounds should be not more than three and one half feet (42 inches) above the floor. This deficient practice could affect staff and 22 residents.

Findings include:

Based on observation with the Director of Engineering Services on 03/29/16 at 3:08 p.m., the Rehabilitation Nurse's station fire extinguisher measured 66 inches from the top of the extinguisher to the floor. Based on interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition and provided the measurement.

Based on observation and interview, the facility failed to ensure the means of egress was continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency for 1 of 16 stairwells. This deficient practice could affect staff only because this stairwell would not be used for patients on the 6th floor or higher.

Findings include:

Based on observation with the Director of Engineering Services on 03/29/16 at 11:57 a.m., in stairwell #2 on the sixth floor was a rolling workbench. The workbench contained a tools, parts, and a large cotton sheet. Based on interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to ensure 1 of 40 cylinders in Gas Storage room 1160 of nonflammable gases such as oxygen were properly chained or supported in a proper cylinder stand or cart. NFPA 99, Health Care Facilities, 8-3.1.11.2(h) requires cylinder or container restraint shall meet NFPA 99, 4-3.5.2.1(b)27 which requires freestanding cylinders be properly chained or supported in a proper cylinder stand or cart. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Engineering Services on 03/30/16 at 12:15 p.m., one argon cylinder was freestanding on the floor in the Gas Storage room 1160. Based on interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition.

Based on record review and interview, the facility failed to ensure the humidity in 10 of 10 Operating Rooms were greater than 35 percent. NFPA 99 5-4.1.1 requires mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater. This deficient practice could affect staff and up to 10 patients.

Findings include:

Based on record review with the Director of Engineering Services on 03/30/16 at 9:32 a.m., the following Operating Rooms were outside of the humidity range:
a) OP 1 was 34
b) OP 2 was 34
c) OP 5 was 34
d) OP 6 was 32
Based on interview at the time of record review, the Director of Engineering Services acknowledged the aforementioned condition.

1. Based on record review and interview, the facility failed to maintain 2 of 6 generators when repairs are needed. This deficient practice could affect all staff, visitors, and patients.

Findings include:

Based on record review with the Director of Engineering Services on 03/29/16 at 12:46 p.m. then again at 12:50 a.m., the annual generator reports from MacAllister indicated that Generator #2 coolant level and the coolant hoses were unsatisfactory. Then again, Generator #4 concentration of coolant conditioner were unsatisfactory. Based on interview at the time of record review, the Director of Engineering Services acknowledged the aforementioned condition.

2. Based on record review and interview, the facility failed to ensure 1 of 1 emergency generators was allowed a 5 minute cool down period after a load test. LSC 19.2.9.1 refers to LSC 7.9 which refers to LSC 7.9.2.3 which requires generators to be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition. NFPA 110, 4-2.4.8 Time Delay on Engine Shutdown requires that a minimum time delay of 5 minutes shall be provided for unloaded running of the Emergency Power Supply (EPS) prior to shut down. This delay provides additional engine cool down. This time delay shall not be required on small (15 kW or less) air-cooled prime movers. This deficient practice could affect all residents, as well as staff and visitors in the facility.

Findings include:

Based on record review of the facility's Emergency Generator monthly testing log on 12/28/15 at 2:07 p.m. with the Administrator, the generator log form documented the generator was tested monthly for at least 30 minutes under load, however, there was no documentation on the form that showed the generator had a cool down time following its load test. Based on interview at the time of record review, the Administrator acknowledged the aforementioned condition.

1. Based on observation and interview, the facility failed to ensure 1 of 1 Staff Lounge #6136, 1 of 1 Clean Room #6146, and 1 of 1 Coffee Room #6145 electrical receptacles in a wet location, was provided with a ground fault circuit interrupter (GFCI) protection against electric shock. LSC sections 9.1.2 requires all electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, Article 210.8 Ground-Fault Circuit-Interrupter Protection for Personnel, in 210.8(A), Dwelling Units, requires ground-fault circuit-interrupter (GFCI) protection for all personnel in bathrooms and kitchens where the receptacles are intended to serve the countertop surfaces. Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice affects staff and at least 12 patients.

Findings include:

Based on observation with the Director of Engineering Services on 03/29/16 between 11:30 a.m. and 2:45 p.m., the following electrical outlets were within 3 feet of a water source and failed to trip when tested:
a) Staff Lounge 6136 in the Bathroom
b) Clean Room 6146
c) Coffee Room 6145
d) 2 North East Nurse's station
Based on observation with the Director of Engineering Services on 03/30/16 at 9:59 a.m., a surge protector was powering another surge protector in the Occupational Therapy room.
Based on interview at the time of each observation, the Director of Engineering Services acknowledged the aforementioned conditions.

2. Based on observation and interview, the facility failed to ensure 6 of 6 flexible cords were not used as a substitute for fixed wiring to provide power equipment with a high current draw. NFPA 70, National Electrical Code, 1999 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 8 patients

Findings include:

Based on observation with the Director of Engineering Services on 03/29/16 between 12:07 p.m. to 2:30 p.m. the following was discovered:
a) a surge protector was powering two separate surge protectors powering battery chargers in the Mechanics Work Bench area
b) a surge protector powering a microwave in the Intensivist's office
c) a surge protector powering another surge protector powering computer equipment in the Critical Care Nurse's station
Based on interview at the time of observation, the Maintenance Director acknowledged each aforementioned condition.

Based on record review and interview, the facility failed to protect all occupants by providing a written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out-of-service for 4 hours or more in a 24-hour period in accordance with LSC, Section 9.7.6.1 in order to protect 57 of 57 residents. 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(d) requires the local fire department be notified of sprinkler impairment and 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified. This deficient practice could affect all staff, visitors, and patients.

Findings include:

Based on record review with the Director of Engineering Services on 03/30/16 at 9:15 a.m., the facility was unable to provide a written policy and procedure for an impaired automatic sprinkler system. Based on an interview at the time of record review, the Director of Engineering Services acknowledged the aforementioned condition.

Based on record review and interview, the facility failed to provide a complete written policy for the protection of all occupants 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 24 hour period 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 affects all staff, visitors, and patients.

Findings include:

Based on record review with the Director of Engineering Services on 03/30/16 at 9:15 a.m., the facility's documentation provided for a plan of action when the fire alarm system was out of service for more than four hours in a twenty four hour period but was not complete. The procedure did not include all elements required such as; the person conducting the fire watch shall have no other duties, contacting the Indiana Department of Health and the local fire department which are the Authority Having Jurisdiction. Based on an interview at the time of record review, the Director of Engineering Services acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to ensure 1 of 1 alcohol based hand sanitizers in the Radiology Room 1 was not installed above or near an ignition source. NFPA 101, in 19.1.1.3 requires all health facilities to be maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants. This deficient practice could affect staff and up to 4 patients.

Findings include:

Based on observation with the Director of Engineering Services on 03/30/16 at 11:40 a.m., an alcohol based hand sanitizer dispenser was mounted on the wall above an outlet in the Radiology Room 1. Based on interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition.

Based on record review and interview, the facility failed to ensure the building construction type was a permitted type as listed in Table 19.1.6.2. Table 19.1.6.2 requires a building, four or more stories in height, to be Type II (222), Type I (332) or Type I (443). This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review with the Director of Engineering Services on 03/29/16 between 8:34 a.m. and 11:24 a.m., part of the Elkhart General Hospital main building was constructed of type II (000) construction. Based on interview at the time of record review, the Director of Engineering Services confirmed part of the hospital was constructed at II (000) and was aware of the aforementioned condition. He further explained that the floor/ceiling rating was constructed of two hours but was unable to provide documentation.

1. Based on observation, the facility failed to ensure 2 of 8 office doors and 1 of 1 triage doors on the fourth floor west protecting corridor openings did not have an impediment to the closing of the doors. This deficient practice could affect approximately 40 patients on the west wing fourth floor.

Findings include:

Based on observation during the tour of the facility with the Manager of Plant Operations on 03/30/16 between 11:15 a.m. and 12:15 p.m., the corridor doors to the Director of Surgery office, the Executive Director of Surgery office, and triage were propped open with a wedge pushed under the door. Based on interview at the time of observation, the Manager of Plant Operations acknowledged that the door wedges were an impediment to closing the doors.

2. Based on observation and interview, the facility failed to ensure 2 of 2 MRI Control Room and 1 of 2 Private Dining Room corridor doors closed and latched into the door frame. This deficient practice could affect staff and up to 2 patients.

Findings include:

Based on observation and interview on 03/30/16 at 11:48 a.m. then again at 2:10 p.m., the Director of Engineering Services acknowledged the two separate corridor doors to the MRI Control Room had a wooden door stop that prevented the door from closing and latching into the door frame. Then again, one of the corridor doors to the Private Dining Room did not contain latching hardware and was unable to latch into the frame.

Based on observation and interview, the facility failed to ensure 1 of 4 of basement stair door assemblies in a vertical opening were of an approved type with appropriate fire protection rating. This deficient practice was not in a patient care area but could affect all staff in the basement.

Finding include:

Based on observation during a tour of the facility with the Manager of Plant Operations on 03/30/16 at 09:30 a.m., the fire rating for the basement stair door #6 protecting a vertical opening could not be determined. Upon inspection of the door, no label could be found to determine the fire rating of the door. Based on interview at the time of observation, the Manager of Plant Operations stated there was no documentation of the door's fire rating and a contractor was scheduled on 04-01-2016 to provide documentation for the door.

1. Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 1 of 1 ceiling barrier and 1 of 1 North PACU smoke barrier wall was 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 8-3. 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 staff and at least 12 patients.

Findings include:

Based on observations with the Director of Engineering Services on 03/29/16 at 2:52 p.m., two separate half inch and one single two inch ceiling penetrations was in the Data Closet Room 2400.
Based on observations with the Director of Engineering Services on 03/30/16 between 10:12 a.m. and 4:03 p.m., the following penetrations were discovered:
a) one eighth inch ceiling penetrations across from the Medical Records office
b) nine separate ceiling penetrations around conduit ranging from an eighth of an inch to an inch in Room 1837A.
c) three of twelve ceiling tiles were missing next to the Security office Room 1837A.
d) a three foot by one foot piece of drywall was removed from the PACU North smoke barrier above the drop ceiling.
Based on interview at the time of observation, the Director of Engineering Services acknowledged each aforementioned condition and provided the measurements.

2. Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 1 of 1 smoke barrier by Woman's Health and 1 of 1 smoke barrier by OBG/YN Associates was 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 8-3. 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 staff and up to 22 patients.

Findings include:

Based on observations with the Manager of Plant Operations on 03/30/16 at 2:50 p.m. then again at 2:51 p.m., the smoke barrier by Woman's Health Room 1965 there was a three inch unsealed penetrations around wires above the drop ceiling. Then again, the smoke barrier near the OBG/YN Associates room were two separate one inch unsealed penetrations above the drop ceiling. Based on interview at the time of each observation, the Manager of Plant Operations acknowledged each aforementioned condition and provided the measurements.

Based on observation and interview, the facility failed to ensure 1 of 3 sets of 4th floor smoke barrier doors would close to form a smoke resistant barrier. This deficient practice could affect staff and at least 12 patients.

Findings include:

Based on observation with the Director of Engineering Services on 03/29/16 at 12:36 p.m., both smoke barrier doors by patient room 4114 caught on the floor when released and failed to close. Based on interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition.

1. Based on observation and interview, the facility failed to ensure corridor doors to 2 of 15 hazardous area in the basement and 1 of 9 hazardous area on first floor west wing, was provided with a self-closing device causing the doors to automatically close and latch into the door frame. This deficient practice could affect up to 90 patients in the west wing of the hospital and all staff in the basement.

Findings include:

Based on an observation during a tour of the facility with the Manager of Plant Operations on 03/30/15 Between 09:00 a.m. and 11:30 a.m., the following doors to hazardous areas lacked a self-closer and/or failed to latch into the frame:
a. the corridor door leading into the basement print shop, which was greater than 50 square feet and contained 400 plus boxes containing supplies, was not equipped with a self-closing device.
b. the corridor door leading into the basement grease trap room, which was greater than 50 square feet and contained 50 plus boxes and a 10 gallon grease trap, was not equipped with a self-closing device.
d. the corridor door to the soiled utility room by the Brest Center, containing barrels of trash and soiled linens, was equipped with a self-closing device but failed to latch into the frame.
Based on interview, this was acknowledged by the Manager of Plant Operations at the time of observations.

2. Based on observation and interview, the facility failed to ensure the corridor door to 1 of 1 6th Floor North PCU Nurse's station, 1 of 1 4th floor Soiled Utility room 4410B, 1 of 1 Patient Room 2409, and 1 of 1 Serving Area containing more than 36 gallons of hazardous soiled linen and or trash in a 64 square foot area, a hazardous area, was not stored in the corridor or provided with self-closer and would latch into the frame. This deficient practice could affect staff and up to least 28 patients.

Findings include:

Based on observation with the Director of Engineering Services on 03/29/16 between 11:50 a.m. and 3:06 p.m., the following was discovered:
a) four separate trash containers totaling 53 gallons in the 6th Floor North PCU Nurse's station
b) two separate soiled utility containers totaling 58 gallons in the 4th floor Soiled Utility room 4410B lacked self-closing device
c) two separate soiled utility containers totaling 60 gallons in the corridor near Patient Room 2409
Based on observation with the Maintenance Supervisor and Maintenance Assistant on 1/7/16 at 9:04 a.m., the following was discovered:
d) three separate trash containers totaling 132 gallons in the Serving Area
Based on interview at the time of each observation, the Director of Engineering Services acknowledged each aforementioned condition.

3. Based on observation and interview, the facility failed to ensure the corridor door to 1 of 1 Room 4115 containing combustible materials greater than 50 square feet, a hazardous area, was provided with self-closer and would latch into the frame. This deficient practice could affect staff and up to 14 patients.

Findings include:

Based on observation with the Director of Engineering Services on 03/30/16 at 12:33 p.m., Room 4115 contained ten wooden chairs, one mattress, and twenty nine large cardboard boxes. The corridor door was not provided with a self-closing device. Based on interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition.

4. Based on observation and interview, the facility failed to ensure the corridor doors to 1 of 1 room kitchen, a hazardous area, would latch into the frame. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Engineering Services on 03/30/16 at 10:42 a.m. then again at 10:46 a.m., one of the kitchen doors self-closed but failed to latch into the frame. Then again, the tray return area was open to the kitchen. A two foot by three foot hole was in the wall for lunch trays to be transported. Based on interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition and provided the measurements.

Based on observation and interview, the facility failed to ensure exit access was arranged so 1 of 3 exits were readily accessible at all times in accordance with LSC Section 7.1. LSC Section 7.1 requires the means of egress for existing buildings shall comply with Chapter 7. LSC Section 7.7.1 requires all exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way. In addition to providing the required width to allow all occupants safe access to a public way, such access also needs to meet the requirements with respect to maintaining the means of egress free of obstructions that would prevent its use, such as snow and the need for its removal in some climates or soft ground during heavy periods of rain. This deficient practice could affects staff, visitors, and at least 3 patients.
Findings include:
Based on observation with the Director of Engineering Services on 03/30/16 at 9:37 a.m., Stair #9 exit discharged into grass. Based on interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition and confirmed that path was considered an exit.

Based on observation and interview, the facility failed to ensure 2 of 7 3rd floor, 1 of 4 2nd floor, and 1 of 4 1st floor fire door sets were arranged to automatically close and latch. LSC 19.2.2.5 requires horizontal exits to be in accordance with 7.2.4 and 7.2.4.3.8 requires fire doors to be self-closing or automatic closing in accordance with 7.2.1.8. In addition NFPA 80, Standard for Fire Doors and Windows at 2-1.4.1 requires all closing mechanisms shall be adjusted to overcome fire resistance of the latch mechanism so that positive latching is achieved on each door operation. These deficient practices could affect staff and up to 54 patients.

Findings include:

Based on observation with the Director of Engineering Services on 03/29/16 at 2:06 p.m. to 2:35 p.m., the following fire barriers failed to latch into the frame when tested:
a) 3rd floor North East Building/ Critical Care
b) 3rd floor East/ West fire doors near room 3742
c) 2nd floor North East by H Elevators

Based on observation with the Director of Engineering Services on 03/30/16 at 12:00 p.m., the 1st floor fire doors near Elevator K failed to latch when tested. Based on interview at the time of each observation, the Director of Engineering Services acknowledged the aforementioned conditions and confirmed the set of doors were fire doors.

Based on record review and interview; the facility failed to ensure 19 of 19 battery operated emergency lights in the facility was maintained in accordance with LSC 7.9. LSC 7.9.3, Periodic Testing of Emergency Lighting Equipment, requires a functional test to be conducted for 30 seconds at 30 day intervals and an annual test to be conducted on every required battery powered emergency lighting system for not less than a 1 ½ hour 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 staff only.

Findings include:

Based on record review with the Director of Engineering Services on 03/29/16 at 2:39 p.m., the battery operated emergency documentation indicated not all the lights received a monthly test on January 2016 and September 2015. January 2016 indicated "unable to complete due to time" and September 2015 indicated "unable to complete." Based on interview at the time of record review, the Director of Engineering Services acknowledged the aforementioned condition.

Based on record review and interview, the facility failed to provide a written plan that addressed all components in 1 of 1 written fire plans. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to the fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
This deficient practice could affect all occupants.

Findings include:

Based on a record review with the Director of Engineering Services on 03/30/16 at 9:28 a.m., the facility had a written fire policy that horizontal evacuation would be performed by crossing a smoke barrier. However, site plans showed there were separation doors on the third floor that was not part of a complete smoke or fire barrier which could cause staff to evacuate residents to a different part of the same smoke compartment and not to an adjacent compartment in the event of a fire. Based on interview during record review, the Director of Engineering Services acknowledged the aforementioned condition and confirmed the site plans indicate separation doors near patient room 3111 were not part of a complete barrier.

Based on observation and interview, the facility failed to ensure 1 of 1 smoke detector near Classroom 2 was not installed where air flow would adversely affect the operation. 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 staff only.

Findings include:

Based on observation with the Director of Engineering Services on 03/30/16 at 3:28 p.m., a smoke detector was located twenty four inches away from an HVAC supply. Based on interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition and provided the measurement.

Based on record review and interview, the facility failed to repair system defects and malfunctions indicated on 1 of 1 fire alarm report. NFPA 72, National Fire Alarm Code, 7-1.1.2 indicates that system defects and malfunctions shall be corrected. This deficient practice could affect staff only.

Findings include:

Based on record review on 03/30/16 between 3:23 p.m. and 3:25 p.m., the annual fire alarm report from ESCO Communications Incorporated indicated the following failed tests:
a) "2nd AHU 521 fan shutdown"
b) "Basement West Wing Rm 926 above Water Fountain 12ft LDR"
c) "Basement West Wing Inside Room 908 smoke detector"
Based on interview at the time or record review, the Director of Engineering Services acknowledged the aforementioned condition.

1. Based on observation and interview, the facility failed to ensure sprinkler coverage in 1 of 1 Stairwell #1 and 1 of 1 Stair #2 was installed in accordance with NFPA 13, 1999 Edition, Installation of Sprinkler Systems, 5-13.3.2 states in noncombustible stair shafts with noncombustible stairs, sprinklers shall be installed at the top of shaft and under the first landing above the bottom of the shaft. This deficient practice could affect staff and up to 185 patients.

Findings include

Based on observation with the Director of Engineering Services on 03/29/16 at 11:44 a.m. then again at 11:59 a.m., stairwell #1 lacked sprinkler coverage at the top of the stairwell. Then again, stairwell #2 lacked sprinkler coverage at the top of the stairwell. Based on interview at the time of each observation, the Director of Engineering Services acknowledged the aforementioned condition.

2. Based on observation and interview, the facility failed to ensure 1 of 5 Radiology office sprinkler heads was installed in accordance with NFPA 13, 1999 Edition, Installation of Sprinkler Systems, 5-3.1.5.2 states when existing light hazard systems are converted to use quick response or residential sprinklers, all sprinklers in a smoke compartment shall be changed. This deficient practice could affect staff up to 5 patients.

Findings include:

Based on observation with the Director of Engineering Services on 03/30/16 at 11:28 a.m., the Radiology office had a mixture of quick response sprinkler heads with the thin glass rod and standard response sprinkler heads with the thick glass rods. Based on an interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition.

3. Based on observation and interview, the facility failed to ensure the spray pattern for 1 of 1 sprinklers in the 5th floor North East Men's Bathroom was unobstructed. NFPA 25, 1998 Edition Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Section 2-2.1.2 states unacceptable obstructions to spray patterns shall be corrected. NFPA 13, 1999 Edition Standard for the Installation of Sprinkler Systems, Table 5-6.5.1.2 states that distance between a sprinkler head an obstruction less than 1 foot away cannot be lower than the sprinkler head deflector. This deficient practice could affect staff and up to 1 patient.

Findings include:

Based on observation with the Director of Engineering Services on 03/29/16 at 12:14 p.m., the spray pattern for the one sprinkler head in 5th floor North East Men's Bathroom was obstructed by a ceiling light. Measurements showed the sprinkler head was 4 inches away from the ceiling light. The ceiling light were measured to be 1 inches lower than the sprinkler head deflector. Based on interview at the time of observation, the Director of Engineering Services acknowledged the abovementioned condition and provided the measurements.

4. Based on observation and interview, the facility failed to ensure that a complete automatic sprinkler system was provided for 1 of 1 canopies in accordance with NFPA 13, Standard for Installation of Sprinkler Systems, to provide complete coverage for all portions of the building. NFPA 13-1999 Edition, Section 5-13.8.1 requires sprinklers shall be installed under exterior roofs or combustible canopies exceeding 4 ft. in width. This deficient practice can affect all patients using the in OB/GYN offices.

Findings include:

Based on observation during a tour of the facility with the Manager of Plant Operations on 03/30/16 at 11:10 a.m., there was an un-sprinkled canvas canopy attached to the building near the OB/GYN entrance. The canvas canopy extends out 20 feet from the building. Based on interview at the time of observation, the Manager of Plant Operations acknowledge that the canopy was attached to the building, provide the measurements of the canopy, and stated there was no documentation to confirm the canvas canopy was inherently fire resistant.

3.1-19(b)
5. Based on observation, record review, and interview, the facility failed to ensure complete sprinkler coverage in 1 of 1 Stairwell #1 and 1 of 1 Mechanical Room 1723 was installed in accordance with NFPA 13, 1999 Edition, Installation of Sprinkler Systems, 1-6.1 state a building where protected by an automatic sprinkler system, shall be provided with sprinkler in all areas. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Engineering Services on 03/30/15 at 12:33 p.m., there was no sprinkler coverage in the Mechanical Room 1723. Based on record review, the site plans failed to indicate a construction rating. Based on interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition.

1. Based on observation and interview, the facility failed to ensure 1 of 1 sprinkler heads in 2nd floor Stairwell #9 was maintained. This deficient practice could affect staff and at least 36 patients.

Findings include:

Based on observations the Director of Engineering Services on 03/29/16 at 3:01 p.m., the 2nd floor Stairwell #9 was missing one escutcheon. Based on interview at the time of observation, the Director of Engineering Services acknowledged the missing escutcheon at the time of each observation.

2. Based on observation and interview, the facility failed to replace 1 of 2 painted sprinkler heads in the Staff Lounge Room 2400. LSC 33.2.3.5.2 refers to LSC section 9.7. 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, 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 staff only.

Findings include:

Based on observation with the Director of Engineering Services on 03/29/16 at 2:54 p.m., one recessed sprinkler head cover was covered in paint in the Staff Lounge Room 2400. Based on interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to ensure 1 of 1 Rehabilitation Nurse's station portable fire extinguishers were installed correctly. NFPA 10, the Standard for Portable Fire Extinguishers, Chapter 1, 1-6.10 requires the top of portable fire extinguishers weighing 40 pounds or less should be no more than five feet (60 inches) above the floor and those weighing more than 40 pounds should be not more than three and one half feet (42 inches) above the floor. This deficient practice could affect staff and 22 residents.

Findings include:

Based on observation with the Director of Engineering Services on 03/29/16 at 3:08 p.m., the Rehabilitation Nurse's station fire extinguisher measured 66 inches from the top of the extinguisher to the floor. Based on interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition and provided the measurement.

Based on observation and interview, the facility failed to ensure the means of egress was continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency for 1 of 16 stairwells. This deficient practice could affect staff only because this stairwell would not be used for patients on the 6th floor or higher.

Findings include:

Based on observation with the Director of Engineering Services on 03/29/16 at 11:57 a.m., in stairwell #2 on the sixth floor was a rolling workbench. The workbench contained a tools, parts, and a large cotton sheet. Based on interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition.

Based on observation and interview, the facility failed to ensure 1 of 40 cylinders in Gas Storage room 1160 of nonflammable gases such as oxygen were properly chained or supported in a proper cylinder stand or cart. NFPA 99, Health Care Facilities, 8-3.1.11.2(h) requires cylinder or container restraint shall meet NFPA 99, 4-3.5.2.1(b)27 which requires freestanding cylinders be properly chained or supported in a proper cylinder stand or cart. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Engineering Services on 03/30/16 at 12:15 p.m., one argon cylinder was freestanding on the floor in the Gas Storage room 1160. Based on interview at the time of observation, the Director of Engineering Services acknowledged the aforementioned condition.

Based on record review and interview, the facility failed to ensure the humidity in 10 of 10 Operating Rooms were greater than 35 percent. NFPA 99 5-4.1.1 requires mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater. This deficient practice could affect staff and up to 10 patients.

Findings include:

Based on record review with the Director of Engineering Services on 03/30/16 at 9:32 a.m., the following Operating Rooms were outside of the humidity range:
a) OP 1 was 34
b) OP 2 was 34
c) OP 5 was 34
d) OP 6 was 32
Based on interview at the time of record review, the Director of Engineering Services acknowledged the aforementioned condition.

1. Based on record review and interview, the facility failed to maintain 2 of 6 generators when repairs are needed. This deficient practice could affect all staff, visitors, and patients.

Findings include:

Based on record review with the Director of Engineering Services on 03/29/16 at 12:46 p.m. then again at 12:50 a.m., the annual generator reports from MacAllister indicated that Generator #2 coolant level and the coolant hoses were unsatisfactory. Then again, Generator #4 concentration of coolant conditioner were unsatisfactory. Based on interview at the time of record review, the Director of Engineering Services acknowledged the aforementioned condition.

2. Based on record review and interview, the facility failed to ensure 1 of 1 emergency generators was allowed a 5 minute cool down period after a load test. LSC 19.2.9.1 refers to LSC 7.9 which refers to LSC 7.9.2.3 which requires generators to be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition. NFPA 110, 4-2.4.8 Time Delay on Engine Shutdown requires that a minimum time delay of 5 minutes shall be provided for unloaded running of the Emergency Power Supply (EPS) prior to shut down. This delay provides additional engine cool down. This time delay shall not be required on small (15 kW or less) air-cooled prime movers. This deficient practice could affect all residents, as well as staff and visitors in the facility.

Findings include:

Based on record review of the facility's Emergency Generator monthly testing log on 12/28/15 at 2:07 p.m. with the Administrator, the generator log form documented the generator was tested monthly for at least 30 minutes under load, however, there was no documentation on the form that showed the generator had a cool down time following its load test. Based on interview at the time of record review, the Administrator acknowledged the aforementioned condition.

1. Based on observation and interview, the facility failed to ensure 1 of 1 Staff Lounge #6136, 1 of 1 Clean Room #6146, and 1 of 1 Coffee Room #6145 electrical receptacles in a wet location, was provided with a ground fault circuit interrupter (GFCI) protection against electric shock. LSC sections 9.1.2 requires all electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, Article 210.8 Ground-Fault Circuit-Interrupter Protection for Personnel, in 210.8(A), Dwelling Units, requires ground-fault circuit-interrupter (GFCI) protection for all personnel in bathrooms and kitchens where the receptacles are intended to serve the countertop surfaces. Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice affects staff and at least 12 patients.

Findings include:

Based on observation with the Director of Engineering Services on 03/29/16 between 11:30 a.m. and 2:45 p.m., the following electrical outlets were within 3 feet of a water source and failed to trip when tested:
a) Staff Lounge 6136 in the Bathroom
b) Clean Room 6146
c) Coffee Room 6145
d) 2 North East Nurse's station
Based on observation with the Director of Engineering Services on 03/30/16 at 9:59 a.m., a surge protector was powering another surge protector in the Occupational Therapy room.
Based on interview at the time of each observation, the Director of Engineering Services acknowledged the aforementioned conditions.

2. Based on observation and interview, the facility failed to ensure 6 of 6 flexible cords were not used as a substitute for fixed wiring to provide power equipment with a high current draw. NFPA 70, National Electrical Code, 1999 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 8 patients

Findings include:

Based on observation with the Director of Engineering Services on 03/29/16 between 12:07 p.m. to 2:30 p.m. the following was discovered:
a) a surge protector was powering two separate surge protectors powering battery chargers in the Mechanics Work Bench area
b) a surge protector powering a microwave in the Intensivist's office
c) a surge protector powering another surge protector powering computer equipment in the Critical Care Nurse's station
Based on interview at the time of observation, the Maintenance Director acknowledged each aforementioned condition.

Based on record review and interview, the facility failed to protect all occupants by providing a written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out-of-service for 4 hours or more in a 24-hour period in accordance with LSC, Section 9.7.6.1 in order to protect 57 of 57 residents. 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(d) requires the local fire department be notified of sprinkler impairment and 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified. This deficient practice could affect all staff, visitors, and patients.

Findings include:

Based on record review with the Director of Engineering Services on 03/30/16 at 9:15 a.m., the facility was unable to provide a written policy and procedure for an impaired automatic sprinkler system. Based on an interview at the time of record review, the Director of Engineering Services acknowledged the aforementioned condition.

Based on record review and interview, the facility failed to provide a complete written policy for the protection of all occupants 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 24 hour period 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 affects all staff, visitors, and patients.

Findings include:

Based on record review with the Director of Engineering Services on 03/30/16 at 9:15 a.m., the facility's documentation provided for a plan of action when the fire alarm system was out of service for more than four hours in a twenty four hour period but was not complete. The procedure did not include all elements required such as; the person conducting the fire watch shall have no other duties, contacting the Indiana Department of Health and the local fire department which are the Authority Having Jurisdiction. Based on an interview at the time of record review, the Director of Engineering Services acknowledged the aforementioned condition.