HospitalInspections.org

1. Based on observation and interview, the facility failed to ensure 2 of 4 open use areas on the second floor were separated from the corridor by walls constructed with at least a thirty minute fire resistance rating extending from the floor to the roof/floor above or met an Exception. LSC 19.3.6.1, Exception #1: Smoke compartments protected throughout by an approved, supervised automatic sprinkler system shall be permitted to have spaces unlimited in size open to the corridor, provided the following criteria are met: (a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas. (b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system, or the smoke compartment in which the space is located is protected throughout by quick response sprinklers. (c) The open space is protected by an electrically supervised automatic smoke detection system, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space. (d) The space does not obstruct access to required exits. This deficient practice could affect 10 or more patients, staff or visitors while in or around the second floor Vending Machine Room and Cafeteria serving area.

Findings include:

Based on observation on 12/08/15 at 12:55 p.m. during a tour of the facility with the Facilities Manager and Safety Director, the second floor Vending Machine Room and the Cafeteria serving area were each open to the corridor without doors separating the rooms from the corridor. Exception #1 requirement (c) of LSC 19.3.6.1 was not met as follows: The second floor Vending Machine Room and the Cafeteria serving area were each not protected by an electrically supervised automatic smoke detection system, or the entire space was not arranged and located to allow direct supervision by the facility staff from a nurses' station or similar staffed space. This was acknowledged by the Facilities Manager and Safety Director at the time of observations.

2. Based on observation and interview, the facility failed to ensure 1 of 1 Allergy and Asthma Office, 1 of 1 Lab Check In Office and 1 of 1 Patient Access Office were separated from the corridor by a partition capable of resisting the passage of smoke as required in a sprinklered building or met an Exception. LSC 19.3.6.1, Exception # 6, Spaces other than patient sleeping rooms, treatment rooms, and hazardous areas may be open to the corridor and unlimited in area provided: (a) The space and corridors which the space opens onto in the same smoke compartment are protected by an electrically supervised automatic smoke detection system, and (b) Each space is protected by automatic sprinklers, and (c) The space is arranged not to obstruct access to required exits. This deficient practice could affect up to 13 patients, as well as staff and visitors.

Findings include:

Based on observations with the Safety Director and the Facilities Manager during a tour of the facility from 1:40 p.m. to 3:00 p.m. on 12/08/15, the Allergy and Asthma Office in the northwest addition portion of the facility had a two foot by two foot sliding glass window to the corridor. There was a one fourth inch gap between the window panes when closed. In addition, the Lab Check In Office on the first floor had a four foot by three foot sliding glass window to the corridor and the Patient Access Office on the first floor had a four foot by five foot sliding glass window each with a one fourth inch gap between the window panes when closed. Furthermore, Exception # 6, requirement (a) of the LSC Section 19-3.6.1 was not met because the aforementioned Offices were each not protected by an electrically supervised automatic smoke detection system. This was acknowledged by the Safety Director and the Facilities Manager at the time of the observations.

1. Based on observation and interview, the facility failed to ensure 1 of 1 Dutch doors was smoke resistant. NFPA 101 at 19.3.6.3.6 states Dutch doors shall be permitted as long as the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel. This deficient practice could affect mostly staff and visitors while in the second floor west hall corridor.

Findings include:

Based on observation on 12/08/15 at 12:34 p.m. during a tour of the facility with the Facilities Manager and Safety Director, The I.T. office in the second floor west hall corridor was equipped with a Dutch door that had a one quarter inch gap between the upper and lower leaves of the door without the use of an astragal, a rabbet, or a bevel. This was acknowledged by the Facilities Manager and Safety Director at the time of observation.

2. Based on observation and interview, the facility failed to ensure 1 of 1 sets of double doors to the corridor in the second floor northwest addition portion of the facility were equipped with positive latches and latched into the door frame automatically. This deficient practice could affect mostly staff and visitors while in the second floor northwest addition north exit corridor.

Findings include:

Based on observation on 12/08/15 at 1:55 p.m. during a tour of the facility with Safety Director, the set of double doors to the clean linen/paper bag closet did not positive latch into the door frame automatically. The left side door had to be manually latched at the top of the door. This was acknowledged by Safety Director at the time of observation.

Based on observation and interview, the facility failed to ensure 1 of 1 kitchen service metal rolling door/window was held open only by a device arranged to automatically close upon activation of the fire alarm system. This deficient practice could affect mostly staff and visitors in the kitchen plus up to 10 patients, staff and visitors while in the Vending Machine Room.

Findings include:

Based on observation on 12/08/15 at 12:50 p.m. during a tour of the facility with the Facilities Manager and Safety Director, the metal rolling service door between the kitchen and adjoining corridor was held open with a chain and fusible links on both sides of the kitchen wall which would not allow the metal rolling door/window to close automatically when the fire alarm system is activated. Based on interview at the time of observation, the Facilities Manager and Safety Director acknowledged the metal rolling door/window between the kitchen and adjoining corridor was held open with a chain and fusible links which would not allow the door/window to close automatically when the fire alarm system was activated.

Based on observation and interview, the facility failed to ensure 2 of 6 ceiling smoke barriers were maintained to provide at least a one half hour fire resistance rating. This deficient practice could affect 10 patients, staff and visitors.

Findings include:

Based on observations with the Facilities Manager during a tour of the facility from 1:40 p.m. to 3:00 p.m. on 12/08/15, the following was noted in ceiling smoke barriers:
a. A one foot by one foot hole was noted in the ceiling above the kitchen fire suppression system cylinders in the Air Handler 7 Room in the kitchen on the second floor.
b. A five inch by eighteen inch hole and a four inch by four inch hole was noted in the ceiling of the Cleaning Chemical Storage Room in the kitchen on the second floor.
c. A one foot by one foot hole was noted in the ceiling of Room 119 (Women's Locker Room) on the first floor.
d. A three foot by eighteen inch suspended ceiling tile was missing in the 1st floor Radiology Storage Room above the LSGB electrical panel. In addition, an eight inch by six inch hole was noted in a ceiling tile of the aforementioned storage room for the passage of six conduits.
Based on interview at the time of the observations, the Facilities Manager acknowledged the aforementioned openings in ceiling smoke barriers failed to maintain at least a one half hour fire resistance rating for the ceiling smoke barrier.

1. Based on observation and interview, the facility failed to ensure 1 of 1 sets of smoke barrier doors on the third floor which swing in the same direction were equipped with the appropriate hardware to allow the door which must close first, always close first so both doors always close completely. Smoke barrier doors equipped with an astragal are required to have a coordinator to ensure the door which must close first always closes first. This deficient practice could affect 8 patients, as well as staff and visitors.

Findings include:

Based on observation on 12/08/15 at 10:52 a.m. during a tour of the facility with the Facilities Manager and Safety Director, the set of smoke barrier doors between the third floor west hall and center nurses' station swung in the same direction and were equipped with a rubber astragal on one of the doors. These smoke barrier doors lacked a coordinator to allow the astragal side to close second, however, this set of smoke barrier doors did close in the correct sequence when tested. This was acknowledged by the Facilities Manager and Safety Director at the time of observation.

2. Based on observation and interview, the facility failed to ensure 1 of 1 sets of smoke barrier doors in the Northwest Addition which swing in the same direction were equipped with the appropriate hardware to allow the door which must close first, always close first so both doors always close completely. Smoke barrier doors equipped with an astragal are required to have a coordinator to ensure the door that must close first always closes first. This deficient practice could affect 10 staff and visitors.

Findings include:

Based on observation with the Facilities Manager during a tour of the facility from 1:40 p.m. to 3:00 p.m. on 12/08/15, the set of smoke barrier doors in the Northwest Addition by the Physician's Lounge swung in the same direction and were equipped with an astragal on one of the doors. These smoke barrier doors lacked a coordinator to allow the astragal side to close second, however, this set of smoke barrier doors did close in the correct sequence when tested. This was acknowledged by the Facilities Manager at the time of observation.

1. Based on observation and interview, the facility failed to ensure 3 of over 20 hazardous area room doors on the second and third floors, such as rooms over 50 square feet containing combustible material, were equipped with self closing devices on the doors. This deficient practice could affect mostly staff and visitors while in third floor Pink Lady storage room, and second floor west hall storage rooms, plus adjoining corridors.

Findings include:

Based on observations on 12/08/15 between 9:20 a.m. and 3:00 p.m. during a tour of the facility with the Facilities Manager and Safety Director, the following was noted:
a. The third floor Pink Lady storage room was over 50 square feet and had over 25 cardboard boxes and plastic/rubber totes full of combustible material. There was no self closing device on the door.
b. Room 232 in the second floor west hall was over 50 square feet and was full of paint cans, cardboard boxes, totes and other combustible items. There was no self closing device on the door.
c. Room 231 (O.R. storage room) in the second floor west hall was over 50 square feet and was full of cardboard boxes, totes and other combustible items. There was no self closing device on the door.
This was acknowledged by the Facilities Manager and Safety Director at the time of each observation.

2. Based on observation and interview, the facility failed to ensure 1 of 1 sets of hazardous area double doors to the corridor, such as kitchen doors, were equipped with positive latches that automatically latched into the door frames when closed. This deficient practice could affect mostly kitchen staff and staff and visitors while in the vicinity of the second floor Vending Machine Room.

Findings include:

Based on observation on 12/08/15 at 1:41 p.m. during a tour of the facility with the Facilities Manager and Safety Director, the set of double doors to the kitchen were not provided with positive latches that automatically latched into the door frames when closed. They were equipped with manual latches located at the top of the inside of the doors. This was acknowledged by the Facilities Manager and Safety Director at the time of observation.

Based on observation and interview, the facility failed to ensure the lighting for 2 of 9 exit means of egress were arranged so the failure of any single lighting fixture (bulb) would not leave the area in darkness. This deficient practice could affect mostly staff and visitors while exiting from the northeast and northwest stairwell exit doors.

Findings include:

Based on observations on 12/08/15 between 9:20 a.m. and 3:00 p.m. during a tour of the facility with the Facilities Manager and Safety Director, the exit means of egress outside the northeast stairwell exit door was equipped with one light fixture with only one bulb, furthermore, the exit means of egress outside the northwest stairwell exit door was not provided with any light fixture. This was acknowledged by the Facilities Manager and Safety Director at the time of each observation.

Based on record review, observation and interview; the facility failed to document testing of emergency lighting in accordance with LSC 7.9 for 11 of 11 battery powered lights for the most recent 12 month period. LSC 7.9.3 Periodic Testing of Emergency Lighting Equipment requires a functional test to be conducted at 30 day intervals for not less than 30 seconds and an annual test to be conducted on every required battery powered emergency lighting system for not less than 1 ½ -hr duration. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Equipment Data" documentation with the Safety Director and the Facilities Manager during the exit conference from 3:00 p.m. to 4:40 p.m. on 12/08/15, documentation of annual testing for not less than 1 ½ -hr duration for facility battery powered emergency lights for the most recent twelve month period was not available for review. Based on observations with the Safety Director and the Facilities Manager during a tour of the facility from 9:20 a.m. to 3:00 p.m. on 12/08/15, a total of eleven battery powered emergency lights were noted in the facility and each battery powered emergency light operated when its respective test button was depressed. Based on interview at the time of the exit conference, the Facilities Manager acknowledged documentation of annual testing for not less than 1 ½ -hr duration for the most recent twelve month period for battery powered emergency lights was not available for review.

Based on record review, observation and interview; the facility failed to include the use of the kitchen range hood fire suppression system in relation to kitchen fire extinguishers for 2 of 2 written fire safety plans for the facility in the event of an emergency. LSC 19.2.2.2 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 three staff and visitors in the kitchen.

Findings include:

Based on review of "Fire/Life Safety Manual" and "Utility Management Program" documentation with the Safety Director and the Facilities Manager during the exit conference from 3:00 p.m. to 4:40 p.m. on 12/08/15, the written fire safety plans for the facility did not address the use of the kitchen range hood fire suppression system in relationship with the use of the kitchen K class fire extinguisher. Based on interview at the time of the exit conference, the Facilities Manager acknowledged the written fire safety plans did not address the use of the range hood suppression system in relationship with the use of the K Class fire extinguisher. Based on observation with the Facilities Manager during a tour of the facility from 1:40 p.m. to 3:00 p.m. on 12/08/15, a portable K Class fire extinguisher was located in the kitchen and a placard was not conspicuously placed near the extinguisher which states the fire protection system shall be activated prior to using the fire extinguisher. Based on interview at the time of observation, the Facilities Manager acknowledged a placard was not conspicuously placed near the extinguisher which states the fire protection system shall be activated prior to using the fire extinguisher.

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

Findings include:

Based on review of "Fire Drill", "Life Safety Observation Results" and "Fire Drill Observer Evaluation " documentation with the Safety Director and the Facilities Manager during the exit conference from 3:00 p.m. to 4:40 p.m. on 12/08/15, third shift fire drills conducted on 03/31/15, 06/30/15, 07/31/15, 08/28/15, 09/07/15 and 10/24/15 were conducted at, respectively, 6:41 a.m., 6:20 a.m., 6:35 a.m., 6:50 a.m., 6:39 a.m. and 6:30 a.m. Based on interview at the time of record review, the Facilities Manager acknowledged third shift fire drills were not conducted at unexpected times under varying conditions.

Based on observation and interview, the facility failed to ensure 18 of over 200 smoke detectors were not installed where air flow would adversely affect their operation. Section 9.6.1.4 requires fire alarm systems comply with NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect all occupants in the facility.

Findings include:

Based on observations on 12/08/15 between 10:00 a.m. and 2:45 p.m. during a tour of the facility with the Facilities Manager and Safety Director, the following was noted:
a. There were ceiling mounted smoke detectors within one foot of air supply vents in the third floor rehab rooms 8,7,4,3, and 2.
b. There was a ceiling mounted smoke detector in the third floor corridor outside room 315 within one foot of an air supply vent.
c. There was a ceiling mounted smoke detector in room 310 within one foot of an air supply vent.
d. There was a ceiling mounted smoke detector in the third floor elevator lobby in the northwest addition within one foot of an air supply vent.
e. There were two ceiling mounted smoke detectors in the third floor northwest addition entrance lobby within one foot of air supply vents.
f. There was a ceiling mounted smoke detector in the third floor northwest addition vending area within one foot of an air supply vent.
g. There was a ceiling mounted smoke detector in the third floor northwest addition Cardio Vascular Unit waiting room within one foot of an air supply vent.
h. There was a ceiling mounted smoke detector in the third floor northwest addition electric room within one foot of an air supply vent.
i. There was a ceiling mounted smoke detector in the third floor Surgery Suite outside room H2 within one foot of an air supply vent.
j. There was a ceiling mounted smoke detector on the second floor outside room 239 within one foot of an air supply vent.
k. There were two ceiling mounted smoke detectors in the corridor outside the main dining room within one foot of air supply vents.
l. There was a ceiling mounted smoke detector in the first floor Respiratory Therapy storage room within one foot of an air supply vent.
This was acknowledged by the Facilities Manager and Safety Director at the time of each observation.

Based on observation and interview, the facility failed to ensure the sprinkler system was installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, 1999 edition, Section 5-6.4.1.1 states the distance between pendent sprinkler deflectors and the ceiling shall be a minimum of one inch and a maximum of twelve inches. This deficient practice could affect 5 staff and visitors in the kitchen.

Findings include:

Based on observations on 12/08/15 between 10:00 a.m. and 2:45 p.m. during a tour of the facility with the Facilities Manager and Safety Director, the following was noted:
a. There were ceiling mounted smoke detectors within one foot of air supply vents in the third floor rehab rooms 8,7,4,3, and 2.
b. There was a ceiling mounted smoke detector in the third floor corridor outside room 315 within one foot of an air supply vent.
c. There was a ceiling mounted smoke detector in room 310 within one foot of an air supply vent.
d. There was a ceiling mounted smoke detector in the third floor elevator lobby in the northwest addition within one foot of an air supply vent.
e. There were two ceiling mounted smoke detectors in the third floor northwest addition entrance lobby within one foot of air supply vents.
f. There was a ceiling mounted smoke detector in the third floor northwest addition vending area within one foot of an air supply vent.
g. There was a ceiling mounted smoke detector in the third floor northwest addition Cardio Vascular Unit waiting room within one foot of an air supply vent.
h. There was a ceiling mounted smoke detector in the third floor northwest addition electric room within one foot of an air supply vent.
i. There was a ceiling mounted smoke detector in the third floor Surgery Suite outside room H2 within one foot of an air supply vent.
j. There was a ceiling mounted smoke detector on the second floor outside room 239 within one foot of an air supply vent.
k. There were two ceiling mounted smoke detectors in the corridor outside the main dining room within one foot of air supply vents.
l. There was a ceiling mounted smoke detector in the first floor Respiratory Therapy storage room within one foot of an air supply vent.
This was acknowledged by the Facilities Manager and Safety Director at the time of each observation.

1. Based on observation and interview, the facility failed to ensure sprinkler heads in 3 of over 2000 sprinkler locations were free of paint. NFPA 101 Section 9.7.5 refers to NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25 2-2.1.1 requires sprinklers to be free of paint. Any sprinkler shall be replaced that is painted. This deficient practice could affect mostly staff while in the Cart Exchange room (room 375), Aid room (room 332), and the I.T. room (room 238).

Findings include:

Based on observations on 12/08/15 between 10:00 a.m. and 3:00 p.m. during a tour of the facility with the Facilities Manager and Safety Director, the following was noted:
a. one of two sprinkler heads in the Cart Exchange room (room 375) was partially covered with paint.
b. the sprinkler head in the Aid room (room 332) was partially covered with paint.
c. the sprinkler head in the I.T. room (room 238) was partially covered with paint.
This was acknowledged by the Facilities Manager and Safety Director at the time of each observation.

2. Based on observation and interview, the facility failed to ensure only one type of sprinkler head, i.e., quick response or standard sprinklers was installed in a compartmented space in 1 of 7 smoke compartments on the first floor. 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 two patients and staff while in the Ambulance Bay.

Findings include:

Based on observation on 12/08/15 at 2:35 p.m. during a tour of the facility with the Safety Director, the Ambulance Bay had a mixture of one green tube upright type sprinkler head which was an intermediate type sprinkler head with a temperature rating of 200 degrees F and three regular standard type pendent sprinkler heads. This was acknowledged by the Safety Director at the time of observation.

Based on observation and interview, the facility failed to maintain 1 of 1 portable fire extinguishers in the kitchen cooking area in accordance with the requirements of NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition. NFPA 10, 2-3.2 requires fire extinguishers provided for the protection of cooking appliances use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires. NFPA 10, 2-3.2.1 requires a placard shall be conspicuously placed near the extinguisher which states the fire protection system shall be activated prior to using the fire extinguisher. Since the fixed fire extinguishing system will automatically shut off the fuel source to the cooking appliance, the fixed system should be activated before using a portable fire extinguisher. In this instance, the portable fire extinguisher is supplemental protection. This deficient practice could affect five staff and visitors in the kitchen.

Findings include:

Based on observation with the Facilities Manager during a tour of the facility from 1:40 p.m. to 3:00 p.m. on 12/08/15, a portable K Class fire extinguisher was located in the kitchen and a placard was not conspicuously placed near the extinguisher which states the fire protection system shall be activated prior to using the fire extinguisher. Based on interview at the time of observation, the Facilities Manager acknowledged a placard was not conspicuously placed near the extinguisher which states the fire protection system shall be activated prior to using the fire extinguisher.


28800

Based on record review and interview, the facility failed to ensure 11 of 93 fire dampers and 14 of 17 smoke dampers in the facility were inspected and provided necessary maintenance at least every six years in accordance with the Centers for Medicare & Medicaid Services (CMS) Survey and Certification Group Memo S&C-10-04-LSC dated 10/30/09. Pursuant to Centers for Medicare & Medicaid Services (CMS) Survey and Certification Group Memo S&C-10-04-LSC dated 10/30/09, hospitals may operate under the six year damper testing cycle of the 2007 edition of NFPA 80, Standard for Fire Doors and Other Opening Protectives without special application to CMS. In addition, NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition, Section 2-3.4.1 states a service opening shall be provided in air ducts adjacent to each fire damper and smoke damper. The opening shall be large enough to permit maintenance and resetting of the device. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on review of Life Safety Services (LSS) "Comprehensive Damper Summary" documentation dated 09/11/15 with the Safety Director and the Facilities Manager during the exit conference from 3:00 p.m. to 4:40 p.m. on 12/08/15, documentation of inspection and maintenance performed for 11 of 93 fire dampers within the last six years on 09/11/15 was listed as "fail." In addition, the aforementioned documentation identified six fire damper locations as failing testing because the fire damper was listed as "non-accessible." The non-accessible locations were identified as:
a. Inside the lab drop off area across from room #115.
b. Two locations across from room #243 for which "pipes blocking" was listed as the reason for being non-accessible.
c. Inside storage room #312.
d. Two locations inside of the penthouse.
The aforementioned documentation of inspection and maintenance performed for 14 of 17 smoke dampers within the last six years on 09/11/15 was listed as "fail." In addition the aforementioned documentation identified three smoke damper locations as failing testing because the smoke damper was listed as "non-accessible." The non-accessible locations were identified as:
a. Above the double doors near room #115.
b. Inside storage room #312.
c. Above the double doors near room #328.
Based on interview at the time of the exit conference, the Facilities Manager stated fire damper and smoke damper accessibility work and retesting was performed recently but stated documentation of retesting the fire dampers and smoke dampers listed as failing 09/11/5 testing was not available for review.

Based on record review and interview, the facility failed to maintain system integrity for 1 of 1 piped gas systems in accordance NFPA 99, Standard for Health Care Facilities, 1999 Edition. NFPA 99 at Chapter 4-3.4.1.1 states inspection and testing shall be performed on all repaired piped gas systems to ensure system integrity has been achieved or maintained. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of Midwest Medical Gas Service "Facility Overview"" documentation dated 07/16/15 with the Safety Director and the Facilities Manager during the exit conference from 3:00 p.m. to 4:40 p.m. on 12/08/15, the piped gas system contractor was unable to locate zone valves for the vacuum system in the OR/Recovery Area. In addition, the aforementioned documentation stated "there is no emergency Oxygen Supply Connection" and "a zone valve on the second floor controls outlets on the second and third floor which is prohibited by NFPA 99". Based on interview at the time of the exit conference, the Facilities Manager stated corrections to the facility's piped gas system had been made recently but acknowledged written documentation of the corrections to the system was not available for review.

Based on observation and interview, the facility failed to ensure power strips were not used as a substitute for fixed wiring in 1 of 8 smoke compartments on the second floor. 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 mostly nursing staff.

Findings include:

Based on observation on 12/08/15 at 2:00 p.m. during a tour of the facility with the Facilities Manager and Safety Director, there was a small refrigerator and microwave plugged into a power strip in the office behind the Day Surgery Nurses' Station. This was acknowledged by the Facilities Manager and Safety Director at the time of observation.

Based on record review and interview, the facility failed to provide a complete written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period in order to protect 13 of 13 patients. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, 1998 Edition, the Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Fire/Life Safety Manual: Fire Watch" and "Utility Management Program: Fire Protection System Failure" documentation with the Safety Director and the Facilities Manager during the exit conference from 3:00 p.m. to 4:40 p.m. on 12/08/15, the written fire watch policy for the facility in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period did not include notification of the Indiana State Department of Health (ISDH) which is an authority having jurisdiction. Based on interview at the time of the exit conference, the Facilities Manager acknowledged the written fire watch policies for the facility in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period did not include notification of ISDH.

Based on record review and interview, the facility failed to provide a complete written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period in accordance with LSC, Section 9.6.1.8 in order to protect 13 of 13 patients. This deficient practice could affect all residents, staff and visitors.

Findings include:

Based on review of "Fire/Life Safety Manual: Fire Watch" and "Utility Management Program: Fire Protection System Failure" documentation with the Safety Director and the Facilities Manager during the exit conference from 3:00 p.m. to 4:40 p.m. on 12/08/15, the written fire watch policies for the facility in the event the fire alarm system is out of service for four hours or more in a 24 hour period did not include notification of the Indiana State Department of Health (ISDH) which is an authority having jurisdiction. Based on interview at the time of the exit conference, the Facilities Manager acknowledged the written fire watch policies for the facility in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period did not include notification of ISDH.

1. Based on observation and interview, the facility failed to ensure 2 of 4 open use areas on the second floor were separated from the corridor by walls constructed with at least a thirty minute fire resistance rating extending from the floor to the roof/floor above or met an Exception. LSC 19.3.6.1, Exception #1: Smoke compartments protected throughout by an approved, supervised automatic sprinkler system shall be permitted to have spaces unlimited in size open to the corridor, provided the following criteria are met: (a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas. (b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system, or the smoke compartment in which the space is located is protected throughout by quick response sprinklers. (c) The open space is protected by an electrically supervised automatic smoke detection system, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space. (d) The space does not obstruct access to required exits. This deficient practice could affect 10 or more patients, staff or visitors while in or around the second floor Vending Machine Room and Cafeteria serving area.

Findings include:

Based on observation on 12/08/15 at 12:55 p.m. during a tour of the facility with the Facilities Manager and Safety Director, the second floor Vending Machine Room and the Cafeteria serving area were each open to the corridor without doors separating the rooms from the corridor. Exception #1 requirement (c) of LSC 19.3.6.1 was not met as follows: The second floor Vending Machine Room and the Cafeteria serving area were each not protected by an electrically supervised automatic smoke detection system, or the entire space was not arranged and located to allow direct supervision by the facility staff from a nurses' station or similar staffed space. This was acknowledged by the Facilities Manager and Safety Director at the time of observations.

2. Based on observation and interview, the facility failed to ensure 1 of 1 Allergy and Asthma Office, 1 of 1 Lab Check In Office and 1 of 1 Patient Access Office were separated from the corridor by a partition capable of resisting the passage of smoke as required in a sprinklered building or met an Exception. LSC 19.3.6.1, Exception # 6, Spaces other than patient sleeping rooms, treatment rooms, and hazardous areas may be open to the corridor and unlimited in area provided: (a) The space and corridors which the space opens onto in the same smoke compartment are protected by an electrically supervised automatic smoke detection system, and (b) Each space is protected by automatic sprinklers, and (c) The space is arranged not to obstruct access to required exits. This deficient practice could affect up to 13 patients, as well as staff and visitors.

Findings include:

Based on observations with the Safety Director and the Facilities Manager during a tour of the facility from 1:40 p.m. to 3:00 p.m. on 12/08/15, the Allergy and Asthma Office in the northwest addition portion of the facility had a two foot by two foot sliding glass window to the corridor. There was a one fourth inch gap between the window panes when closed. In addition, the Lab Check In Office on the first floor had a four foot by three foot sliding glass window to the corridor and the Patient Access Office on the first floor had a four foot by five foot sliding glass window each with a one fourth inch gap between the window panes when closed. Furthermore, Exception # 6, requirement (a) of the LSC Section 19-3.6.1 was not met because the aforementioned Offices were each not protected by an electrically supervised automatic smoke detection system. This was acknowledged by the Safety Director and the Facilities Manager at the time of the observations.

1. Based on observation and interview, the facility failed to ensure 1 of 1 Dutch doors was smoke resistant. NFPA 101 at 19.3.6.3.6 states Dutch doors shall be permitted as long as the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel. This deficient practice could affect mostly staff and visitors while in the second floor west hall corridor.

Findings include:

Based on observation on 12/08/15 at 12:34 p.m. during a tour of the facility with the Facilities Manager and Safety Director, The I.T. office in the second floor west hall corridor was equipped with a Dutch door that had a one quarter inch gap between the upper and lower leaves of the door without the use of an astragal, a rabbet, or a bevel. This was acknowledged by the Facilities Manager and Safety Director at the time of observation.

2. Based on observation and interview, the facility failed to ensure 1 of 1 sets of double doors to the corridor in the second floor northwest addition portion of the facility were equipped with positive latches and latched into the door frame automatically. This deficient practice could affect mostly staff and visitors while in the second floor northwest addition north exit corridor.

Findings include:

Based on observation on 12/08/15 at 1:55 p.m. during a tour of the facility with Safety Director, the set of double doors to the clean linen/paper bag closet did not positive latch into the door frame automatically. The left side door had to be manually latched at the top of the door. This was acknowledged by Safety Director at the time of observation.

Based on observation and interview, the facility failed to ensure 1 of 1 kitchen service metal rolling door/window was held open only by a device arranged to automatically close upon activation of the fire alarm system. This deficient practice could affect mostly staff and visitors in the kitchen plus up to 10 patients, staff and visitors while in the Vending Machine Room.

Findings include:

Based on observation on 12/08/15 at 12:50 p.m. during a tour of the facility with the Facilities Manager and Safety Director, the metal rolling service door between the kitchen and adjoining corridor was held open with a chain and fusible links on both sides of the kitchen wall which would not allow the metal rolling door/window to close automatically when the fire alarm system is activated. Based on interview at the time of observation, the Facilities Manager and Safety Director acknowledged the metal rolling door/window between the kitchen and adjoining corridor was held open with a chain and fusible links which would not allow the door/window to close automatically when the fire alarm system was activated.

Based on observation and interview, the facility failed to ensure 2 of 6 ceiling smoke barriers were maintained to provide at least a one half hour fire resistance rating. This deficient practice could affect 10 patients, staff and visitors.

Findings include:

Based on observations with the Facilities Manager during a tour of the facility from 1:40 p.m. to 3:00 p.m. on 12/08/15, the following was noted in ceiling smoke barriers:
a. A one foot by one foot hole was noted in the ceiling above the kitchen fire suppression system cylinders in the Air Handler 7 Room in the kitchen on the second floor.
b. A five inch by eighteen inch hole and a four inch by four inch hole was noted in the ceiling of the Cleaning Chemical Storage Room in the kitchen on the second floor.
c. A one foot by one foot hole was noted in the ceiling of Room 119 (Women's Locker Room) on the first floor.
d. A three foot by eighteen inch suspended ceiling tile was missing in the 1st floor Radiology Storage Room above the LSGB electrical panel. In addition, an eight inch by six inch hole was noted in a ceiling tile of the aforementioned storage room for the passage of six conduits.
Based on interview at the time of the observations, the Facilities Manager acknowledged the aforementioned openings in ceiling smoke barriers failed to maintain at least a one half hour fire resistance rating for the ceiling smoke barrier.

1. Based on observation and interview, the facility failed to ensure 1 of 1 sets of smoke barrier doors on the third floor which swing in the same direction were equipped with the appropriate hardware to allow the door which must close first, always close first so both doors always close completely. Smoke barrier doors equipped with an astragal are required to have a coordinator to ensure the door which must close first always closes first. This deficient practice could affect 8 patients, as well as staff and visitors.

Findings include:

Based on observation on 12/08/15 at 10:52 a.m. during a tour of the facility with the Facilities Manager and Safety Director, the set of smoke barrier doors between the third floor west hall and center nurses' station swung in the same direction and were equipped with a rubber astragal on one of the doors. These smoke barrier doors lacked a coordinator to allow the astragal side to close second, however, this set of smoke barrier doors did close in the correct sequence when tested. This was acknowledged by the Facilities Manager and Safety Director at the time of observation.

2. Based on observation and interview, the facility failed to ensure 1 of 1 sets of smoke barrier doors in the Northwest Addition which swing in the same direction were equipped with the appropriate hardware to allow the door which must close first, always close first so both doors always close completely. Smoke barrier doors equipped with an astragal are required to have a coordinator to ensure the door that must close first always closes first. This deficient practice could affect 10 staff and visitors.

Findings include:

Based on observation with the Facilities Manager during a tour of the facility from 1:40 p.m. to 3:00 p.m. on 12/08/15, the set of smoke barrier doors in the Northwest Addition by the Physician's Lounge swung in the same direction and were equipped with an astragal on one of the doors. These smoke barrier doors lacked a coordinator to allow the astragal side to close second, however, this set of smoke barrier doors did close in the correct sequence when tested. This was acknowledged by the Facilities Manager at the time of observation.

1. Based on observation and interview, the facility failed to ensure 3 of over 20 hazardous area room doors on the second and third floors, such as rooms over 50 square feet containing combustible material, were equipped with self closing devices on the doors. This deficient practice could affect mostly staff and visitors while in third floor Pink Lady storage room, and second floor west hall storage rooms, plus adjoining corridors.

Findings include:

Based on observations on 12/08/15 between 9:20 a.m. and 3:00 p.m. during a tour of the facility with the Facilities Manager and Safety Director, the following was noted:
a. The third floor Pink Lady storage room was over 50 square feet and had over 25 cardboard boxes and plastic/rubber totes full of combustible material. There was no self closing device on the door.
b. Room 232 in the second floor west hall was over 50 square feet and was full of paint cans, cardboard boxes, totes and other combustible items. There was no self closing device on the door.
c. Room 231 (O.R. storage room) in the second floor west hall was over 50 square feet and was full of cardboard boxes, totes and other combustible items. There was no self closing device on the door.
This was acknowledged by the Facilities Manager and Safety Director at the time of each observation.

2. Based on observation and interview, the facility failed to ensure 1 of 1 sets of hazardous area double doors to the corridor, such as kitchen doors, were equipped with positive latches that automatically latched into the door frames when closed. This deficient practice could affect mostly kitchen staff and staff and visitors while in the vicinity of the second floor Vending Machine Room.

Findings include:

Based on observation on 12/08/15 at 1:41 p.m. during a tour of the facility with the Facilities Manager and Safety Director, the set of double doors to the kitchen were not provided with positive latches that automatically latched into the door frames when closed. They were equipped with manual latches located at the top of the inside of the doors. This was acknowledged by the Facilities Manager and Safety Director at the time of observation.

Based on observation and interview, the facility failed to ensure the lighting for 2 of 9 exit means of egress were arranged so the failure of any single lighting fixture (bulb) would not leave the area in darkness. This deficient practice could affect mostly staff and visitors while exiting from the northeast and northwest stairwell exit doors.

Findings include:

Based on observations on 12/08/15 between 9:20 a.m. and 3:00 p.m. during a tour of the facility with the Facilities Manager and Safety Director, the exit means of egress outside the northeast stairwell exit door was equipped with one light fixture with only one bulb, furthermore, the exit means of egress outside the northwest stairwell exit door was not provided with any light fixture. This was acknowledged by the Facilities Manager and Safety Director at the time of each observation.

Based on record review, observation and interview; the facility failed to document testing of emergency lighting in accordance with LSC 7.9 for 11 of 11 battery powered lights for the most recent 12 month period. LSC 7.9.3 Periodic Testing of Emergency Lighting Equipment requires a functional test to be conducted at 30 day intervals for not less than 30 seconds and an annual test to be conducted on every required battery powered emergency lighting system for not less than 1 ½ -hr duration. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Equipment Data" documentation with the Safety Director and the Facilities Manager during the exit conference from 3:00 p.m. to 4:40 p.m. on 12/08/15, documentation of annual testing for not less than 1 ½ -hr duration for facility battery powered emergency lights for the most recent twelve month period was not available for review. Based on observations with the Safety Director and the Facilities Manager during a tour of the facility from 9:20 a.m. to 3:00 p.m. on 12/08/15, a total of eleven battery powered emergency lights were noted in the facility and each battery powered emergency light operated when its respective test button was depressed. Based on interview at the time of the exit conference, the Facilities Manager acknowledged documentation of annual testing for not less than 1 ½ -hr duration for the most recent twelve month period for battery powered emergency lights was not available for review.

Based on record review, observation and interview; the facility failed to include the use of the kitchen range hood fire suppression system in relation to kitchen fire extinguishers for 2 of 2 written fire safety plans for the facility in the event of an emergency. LSC 19.2.2.2 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 three staff and visitors in the kitchen.

Findings include:

Based on review of "Fire/Life Safety Manual" and "Utility Management Program" documentation with the Safety Director and the Facilities Manager during the exit conference from 3:00 p.m. to 4:40 p.m. on 12/08/15, the written fire safety plans for the facility did not address the use of the kitchen range hood fire suppression system in relationship with the use of the kitchen K class fire extinguisher. Based on interview at the time of the exit conference, the Facilities Manager acknowledged the written fire safety plans did not address the use of the range hood suppression system in relationship with the use of the K Class fire extinguisher. Based on observation with the Facilities Manager during a tour of the facility from 1:40 p.m. to 3:00 p.m. on 12/08/15, a portable K Class fire extinguisher was located in the kitchen and a placard was not conspicuously placed near the extinguisher which states the fire protection system shall be activated prior to using the fire extinguisher. Based on interview at the time of observation, the Facilities Manager acknowledged a placard was not conspicuously placed near the extinguisher which states the fire protection system shall be activated prior to using the fire extinguisher.

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

Findings include:

Based on review of "Fire Drill", "Life Safety Observation Results" and "Fire Drill Observer Evaluation " documentation with the Safety Director and the Facilities Manager during the exit conference from 3:00 p.m. to 4:40 p.m. on 12/08/15, third shift fire drills conducted on 03/31/15, 06/30/15, 07/31/15, 08/28/15, 09/07/15 and 10/24/15 were conducted at, respectively, 6:41 a.m., 6:20 a.m., 6:35 a.m., 6:50 a.m., 6:39 a.m. and 6:30 a.m. Based on interview at the time of record review, the Facilities Manager acknowledged third shift fire drills were not conducted at unexpected times under varying conditions.

Based on observation and interview, the facility failed to ensure 18 of over 200 smoke detectors were not installed where air flow would adversely affect their operation. Section 9.6.1.4 requires fire alarm systems comply with NFPA 72, National Fire Alarm Code. NFPA 72, 2-3.5.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could affect all occupants in the facility.

Findings include:

Based on observations on 12/08/15 between 10:00 a.m. and 2:45 p.m. during a tour of the facility with the Facilities Manager and Safety Director, the following was noted:
a. There were ceiling mounted smoke detectors within one foot of air supply vents in the third floor rehab rooms 8,7,4,3, and 2.
b. There was a ceiling mounted smoke detector in the third floor corridor outside room 315 within one foot of an air supply vent.
c. There was a ceiling mounted smoke detector in room 310 within one foot of an air supply vent.
d. There was a ceiling mounted smoke detector in the third floor elevator lobby in the northwest addition within one foot of an air supply vent.
e. There were two ceiling mounted smoke detectors in the third floor northwest addition entrance lobby within one foot of air supply vents.
f. There was a ceiling mounted smoke detector in the third floor northwest addition vending area within one foot of an air supply vent.
g. There was a ceiling mounted smoke detector in the third floor northwest addition Cardio Vascular Unit waiting room within one foot of an air supply vent.
h. There was a ceiling mounted smoke detector in the third floor northwest addition electric room within one foot of an air supply vent.
i. There was a ceiling mounted smoke detector in the third floor Surgery Suite outside room H2 within one foot of an air supply vent.
j. There was a ceiling mounted smoke detector on the second floor outside room 239 within one foot of an air supply vent.
k. There were two ceiling mounted smoke detectors in the corridor outside the main dining room within one foot of air supply vents.
l. There was a ceiling mounted smoke detector in the first floor Respiratory Therapy storage room within one foot of an air supply vent.
This was acknowledged by the Facilities Manager and Safety Director at the time of each observation.

Based on observation and interview, the facility failed to ensure the sprinkler system was installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, 1999 edition, Section 5-6.4.1.1 states the distance between pendent sprinkler deflectors and the ceiling shall be a minimum of one inch and a maximum of twelve inches. This deficient practice could affect 5 staff and visitors in the kitchen.

Findings include:

Based on observations on 12/08/15 between 10:00 a.m. and 2:45 p.m. during a tour of the facility with the Facilities Manager and Safety Director, the following was noted:
a. There were ceiling mounted smoke detectors within one foot of air supply vents in the third floor rehab rooms 8,7,4,3, and 2.
b. There was a ceiling mounted smoke detector in the third floor corridor outside room 315 within one foot of an air supply vent.
c. There was a ceiling mounted smoke detector in room 310 within one foot of an air supply vent.
d. There was a ceiling mounted smoke detector in the third floor elevator lobby in the northwest addition within one foot of an air supply vent.
e. There were two ceiling mounted smoke detectors in the third floor northwest addition entrance lobby within one foot of air supply vents.
f. There was a ceiling mounted smoke detector in the third floor northwest addition vending area within one foot of an air supply vent.
g. There was a ceiling mounted smoke detector in the third floor northwest addition Cardio Vascular Unit waiting room within one foot of an air supply vent.
h. There was a ceiling mounted smoke detector in the third floor northwest addition electric room within one foot of an air supply vent.
i. There was a ceiling mounted smoke detector in the third floor Surgery Suite outside room H2 within one foot of an air supply vent.
j. There was a ceiling mounted smoke detector on the second floor outside room 239 within one foot of an air supply vent.
k. There were two ceiling mounted smoke detectors in the corridor outside the main dining room within one foot of air supply vents.
l. There was a ceiling mounted smoke detector in the first floor Respiratory Therapy storage room within one foot of an air supply vent.
This was acknowledged by the Facilities Manager and Safety Director at the time of each observation.

1. Based on observation and interview, the facility failed to ensure sprinkler heads in 3 of over 2000 sprinkler locations were free of paint. NFPA 101 Section 9.7.5 refers to NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25 2-2.1.1 requires sprinklers to be free of paint. Any sprinkler shall be replaced that is painted. This deficient practice could affect mostly staff while in the Cart Exchange room (room 375), Aid room (room 332), and the I.T. room (room 238).

Findings include:

Based on observations on 12/08/15 between 10:00 a.m. and 3:00 p.m. during a tour of the facility with the Facilities Manager and Safety Director, the following was noted:
a. one of two sprinkler heads in the Cart Exchange room (room 375) was partially covered with paint.
b. the sprinkler head in the Aid room (room 332) was partially covered with paint.
c. the sprinkler head in the I.T. room (room 238) was partially covered with paint.
This was acknowledged by the Facilities Manager and Safety Director at the time of each observation.

2. Based on observation and interview, the facility failed to ensure only one type of sprinkler head, i.e., quick response or standard sprinklers was installed in a compartmented space in 1 of 7 smoke compartments on the first floor. 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 two patients and staff while in the Ambulance Bay.

Findings include:

Based on observation on 12/08/15 at 2:35 p.m. during a tour of the facility with the Safety Director, the Ambulance Bay had a mixture of one green tube upright type sprinkler head which was an intermediate type sprinkler head with a temperature rating of 200 degrees F and three regular standard type pendent sprinkler heads. This was acknowledged by the Safety Director at the time of observation.

Based on observation and interview, the facility failed to maintain 1 of 1 portable fire extinguishers in the kitchen cooking area in accordance with the requirements of NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition. NFPA 10, 2-3.2 requires fire extinguishers provided for the protection of cooking appliances use combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires. NFPA 10, 2-3.2.1 requires a placard shall be conspicuously placed near the extinguisher which states the fire protection system shall be activated prior to using the fire extinguisher. Since the fixed fire extinguishing system will automatically shut off the fuel source to the cooking appliance, the fixed system should be activated before using a portable fire extinguisher. In this instance, the portable fire extinguisher is supplemental protection. This deficient practice could affect five staff and visitors in the kitchen.

Findings include:

Based on observation with the Facilities Manager during a tour of the facility from 1:40 p.m. to 3:00 p.m. on 12/08/15, a portable K Class fire extinguisher was located in the kitchen and a placard was not conspicuously placed near the extinguisher which states the fire protection system shall be activated prior to using the fire extinguisher. Based on interview at the time of observation, the Facilities Manager acknowledged a placard was not conspicuously placed near the extinguisher which states the fire protection system shall be activated prior to using the fire extinguisher.


28800

Based on record review and interview, the facility failed to ensure 11 of 93 fire dampers and 14 of 17 smoke dampers in the facility were inspected and provided necessary maintenance at least every six years in accordance with the Centers for Medicare & Medicaid Services (CMS) Survey and Certification Group Memo S&C-10-04-LSC dated 10/30/09. Pursuant to Centers for Medicare & Medicaid Services (CMS) Survey and Certification Group Memo S&C-10-04-LSC dated 10/30/09, hospitals may operate under the six year damper testing cycle of the 2007 edition of NFPA 80, Standard for Fire Doors and Other Opening Protectives without special application to CMS. In addition, NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition, Section 2-3.4.1 states a service opening shall be provided in air ducts adjacent to each fire damper and smoke damper. The opening shall be large enough to permit maintenance and resetting of the device. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on review of Life Safety Services (LSS) "Comprehensive Damper Summary" documentation dated 09/11/15 with the Safety Director and the Facilities Manager during the exit conference from 3:00 p.m. to 4:40 p.m. on 12/08/15, documentation of inspection and maintenance performed for 11 of 93 fire dampers within the last six years on 09/11/15 was listed as "fail." In addition, the aforementioned documentation identified six fire damper locations as failing testing because the fire damper was listed as "non-accessible." The non-accessible locations were identified as:
a. Inside the lab drop off area across from room #115.
b. Two locations across from room #243 for which "pipes blocking" was listed as the reason for being non-accessible.
c. Inside storage room #312.
d. Two locations inside of the penthouse.
The aforementioned documentation of inspection and maintenance performed for 14 of 17 smoke dampers within the last six years on 09/11/15 was listed as "fail." In addition the aforementioned documentation identified three smoke damper locations as failing testing because the smoke damper was listed as "non-accessible." The non-accessible locations were identified as:
a. Above the double doors near room #115.
b. Inside storage room #312.
c. Above the double doors near room #328.
Based on interview at the time of the exit conference, the Facilities Manager stated fire damper and smoke damper accessibility work and retesting was performed recently but stated documentation of retesting the fire dampers and smoke dampers listed as failing 09/11/5 testing was not available for review.

Based on record review and interview, the facility failed to maintain system integrity for 1 of 1 piped gas systems in accordance NFPA 99, Standard for Health Care Facilities, 1999 Edition. NFPA 99 at Chapter 4-3.4.1.1 states inspection and testing shall be performed on all repaired piped gas systems to ensure system integrity has been achieved or maintained. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of Midwest Medical Gas Service "Facility Overview"" documentation dated 07/16/15 with the Safety Director and the Facilities Manager during the exit conference from 3:00 p.m. to 4:40 p.m. on 12/08/15, the piped gas system contractor was unable to locate zone valves for the vacuum system in the OR/Recovery Area. In addition, the aforementioned documentation stated "there is no emergency Oxygen Supply Connection" and "a zone valve on the second floor controls outlets on the second and third floor which is prohibited by NFPA 99". Based on interview at the time of the exit conference, the Facilities Manager stated corrections to the facility's piped gas system had been made recently but acknowledged written documentation of the corrections to the system was not available for review.

Based on observation and interview, the facility failed to ensure power strips were not used as a substitute for fixed wiring in 1 of 8 smoke compartments on the second floor. 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 mostly nursing staff.

Findings include:

Based on observation on 12/08/15 at 2:00 p.m. during a tour of the facility with the Facilities Manager and Safety Director, there was a small refrigerator and microwave plugged into a power strip in the office behind the Day Surgery Nurses' Station. This was acknowledged by the Facilities Manager and Safety Director at the time of observation.

Based on record review and interview, the facility failed to provide a complete written policy containing procedures to be followed in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period in order to protect 13 of 13 patients. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, 1998 Edition, the Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Fire/Life Safety Manual: Fire Watch" and "Utility Management Program: Fire Protection System Failure" documentation with the Safety Director and the Facilities Manager during the exit conference from 3:00 p.m. to 4:40 p.m. on 12/08/15, the written fire watch policy for the facility in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period did not include notification of the Indiana State Department of Health (ISDH) which is an authority having jurisdiction. Based on interview at the time of the exit conference, the Facilities Manager acknowledged the written fire watch policies for the facility in the event the automatic sprinkler system has to be placed out of service for four hours or more in a 24 hour period did not include notification of ISDH.

Based on record review and interview, the facility failed to provide a complete written policy containing procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period in accordance with LSC, Section 9.6.1.8 in order to protect 13 of 13 patients. This deficient practice could affect all residents, staff and visitors.

Findings include:

Based on review of "Fire/Life Safety Manual: Fire Watch" and "Utility Management Program: Fire Protection System Failure" documentation with the Safety Director and the Facilities Manager during the exit conference from 3:00 p.m. to 4:40 p.m. on 12/08/15, the written fire watch policies for the facility in the event the fire alarm system is out of service for four hours or more in a 24 hour period did not include notification of the Indiana State Department of Health (ISDH) which is an authority having jurisdiction. Based on interview at the time of the exit conference, the Facilities Manager acknowledged the written fire watch policies for the facility in the event the fire alarm system has to be placed out of service for four hours or more in a 24 hour period did not include notification of ISDH.