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Based on observation and interview, the facility failed to maintain the building construction type in 1 of over 100 rooms. This deficient practice could affect five staff and visitors.

Findings include:

Based on observations with the Chief Financial Officer (CFO) and the Maintenance Assistant during a tour of the facility from 10:20 a.m. to 2:50 p.m. on 05/30/17, a ten inch by ten inch hole was noted in one layer of drywall above the refrigerator in the storage room by the Maintenance Office which exposed the metal studs for the wall and failed to maintain the building construction type for all portions of the building. Based on interview at the time of the observations, the Chief Financial Officer (CFO) and the Maintenance Assistant acknowledged the building construction type was not maintained due the aforementioned hole in the wall.

Based on observation and interview, the facility failed to ensure 1 of 5 exit discharge walking surfaces were nominally level and did not have abrupt changes in elevation. This deficient practice could affect 10 patients if needing to exit the facility from the gymnasium.

Findings include:

Based on observations with the Chief Financial Officer (CFO) and the Maintenance Assistant during a tour of the facility from 10:20 a.m. to 2:50 p.m. on 05/30/17, the gymnasium exit discharge was hard packed concrete but was more than one inch lower than the threshold for the exit door frame. In addition, the hard packed concrete for the discharge was cracked in three places with the cracks exposing one inch gaps in between three concrete sections which were not level with one another over a three foot section of the discharge immediately outside the exit door. Based on interview at the time of the observations, the CFO acknowledged the gymnasium exit discharge was not nominally level and had abrupt changes in elevation.

Based on observation and interview, the facility failed to ensure 4 of 9 battery powered emergency lights were maintained in accordance with LSC 7.9. LSC 7.9.2.6 states battery operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70 National Electric Code. LSC 7.9.2.7 states the emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation without manual intervention. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on observations with the Chief Financial Officer (CFO) and the Maintenance Assistant during a tour of the facility from 10:20 a.m. to 2:50 p.m. on 05/30/17, four of nine battery operated emergency lights in the facility failed to illuminate when their respective test button was pushed at least five times. The battery light locations which failed to illuminate were at the facility transfer switch room by the Maintenance Office storage room, the employee exit, the Patient Access entrance and by Assessment Rooms 7 & 8 near the Patient Access entrance. Based on interview at the time of the observations, the CFO and the Maintenance Assistant Plant Operations Manager stated battery operated lights in the facility are tested frequently but acknowledged the aforementioned four battery operated emergency lights failed to function when its respective test button was pushed.

Based on record review and interview, the facility failed to provide a complete 1 of 1 written policy for the protection of patients indicating procedures to be followed in the event the fire alarm system has to be placed out of service for four hours or more in a twenty four hour period in accordance with LSC, Section 9.6.1.6. This deficient practice affects all patients in the facility.

Findings include:

Based on record review with the director of plant operations on 05/30/17 at 10:25 a.m., the facility provided fire watch documentation in the event the fire alarm system has to be placed out of service which was labeled Fire Watch Policy # 7.4 dated 04/23/12 lacked notification and telephone numbers of the Indiana State Department of Health, the local fire department, the insurance carrier and lacked identification of trained staff to perform the fire watch. This was verified by the director of plant operations at the time of record review and acknowledged by the chief executive officer at the exit conference on 05/30/17 at 3:00 p.m.

1. Based on record review and interview, the facility failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 2 of 4 quarters over the past year. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request. 4.3.2 requires that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. NFPA 25, 5.2.5 requires that waterflow alarm devices shall be inspected quarterly to verify they are free of physical damage. NFPA 25, 5.3.3.1 requires the mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly. 5.3.3.2 requires vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on record review with the director of plant operations on 05/30/17 at 10:45 a.m., Hydro Fire Protection Inc. Reports of quarterly sprinkler inspection reports were provided for review and indicated the following quarterly sprinkler inspection dates; 05/07/17, 09/29/16, 06/10/16, 03/22/16. Based on an interview with the director of plant operations at the time of record review, when asked if a first quarter 2017 sprinkler inspection and fourth quarter 2016 sprinkler inspection had been conducted over the past year, the director of plant operations indicated there were no records available for review to indicate a first quarter 2017 sprinkler inspection and fourth quarter 2016 sprinkler inspection had been conducted. The lack of documentation of a first quarter 2017 and fourth quarter 2016 sprinkler inspection had been conducted was verified by the director of plant operations at the time of record review and acknowledged by the chief executive officer at the exit conference on 05/30/17 at 3:00 p.m.

2. Based on observation, record review and interview, the facility failed to ensure 2 of 4 sprinkler system riser gauges were replaced or recalibrated every 5 years in accordance with NFPA 25. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.3.2.1 states gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observation on 05/30/17 from 11:50 a.m. to 12:10 p.m. with the director of plant operations, the one sprinkler riser room #4 sprinkler gauge and the one sprinkler riser room #3 sprinkler gauge were dated March 2010, which was a period exceeding the five year replacement or recalibration requirement. Based on a review of sprinkler system quarterly inspection reports on 05/30/17 at 10:45 a.m. with the director of plant operations, the Hydro Fire Protection Inc. quarterly sprinkler inspection reports dated 05/07/17, 09/29/16, 06/10/16, and 03/22/16 failed to indicate replacement or recalibration of sprinkler riser room #4 and sprinkler riser room #3 gauges. This was verified by the director of plant operations at the time of observation and interview and acknowledged by the chief executive officer at the exit conference on 05/30/17 at 3:00 p.m.

3. Based on observation and interview, the facility failed to ensure 1 of over 100 sprinkler heads in the facility were maintained. NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 6.2.7.2 states escutcheons used with recessed, flush-type or concealed sprinklers shall be part of a listed sprinkler assembly. This deficient practice could affect 15 patients, staff and visitors.

Findings include:

Based on observations with the Chief Financial Officer (CFO) and the Maintenance Assistant during a tour of the facility from 10:20 a.m. to 2:50 p.m. on 05/30/17, the recessed sprinkler located in the Information Technology (IT) Room at the 4-5 West nurse's station was missing its cover plate. Based on interview at the time of the observations, the CFO acknowledged the aforementioned sprinkler location had a missing cover plate.

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

Findings include:

Based on record review with the director of plant operations on 05/30/17 at 10:25 a.m., the facility provided fire watch documentation in the event the sprinkler system has to be placed out of service which was labeled Fire Watch Policy # 7.4 dated 04/23/12 lacked notification and telephone numbers of the Indiana State Department of Health, the local fire department, the insurance carrier and lacked identification of trained staff to perform the fire watch. This was verified by the director of plant operations at the time of record review and acknowledged by the chief executive officer at the exit conference on 05/30/17 at 3:00 p.m.

Based on observation and interview, the facility failed to ensure 1 of over 75 corridor doors were provided with a means suitable for keeping the door closed, had no impediment to closing, latching and would resist the passage of smoke. This deficient practice could affect 10 patients, staff and visitors in 3 West.

Findings include:

Based on observations with the Chief Financial Officer (CFO) and the Maintenance Assistant during a tour of the facility from 10:20 a.m. to 2:50 p.m. on 05/30/17, the corridor door serving as the entrance to the Doctor's Office in 3 West was propped in the fully open position with a wedge placed on the floor. Based on interview at the time of observation, the CFO acknowledged the aforementioned corridor door was propped in the fully open position with a wedge placed on the floor.

1. Based on record review, observation and interview; the facility failed to ensure openings through 2 of 20 smoke barrier walls were protected to maintain the fire resistance rating of the smoke barrier. LSC 19.3.7.3 refers to Section 8.5. Section 8.5.6.2 states penetrations for cables, conduits, pipes and similar items that pass through a wall constructed as a smoke barrier shall be protected by a system or material capable of resisting the transfer of smoke. Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of Section 8.3.5 to limit the spread of fire for a time period equal to the fire resistance of the assembly and Section 8.5.6. This deficient practice could affect 20 patients, staff and visitors.

Findings include:

Based on review of facility floor plan information for the attic with the Maintenance Supervisor and Maintenance Assistant at 2:40 p.m. on 05/30/17, six cross corridor smoke barrier walls extending through the first floor ceiling through the attic and to the roof deck above were identified. Based on observations with the Maintenance Supervisor and the Maintenance Assistant during a tour of the facility from 2:40 p.m. to 2:50 p.m. on 05/30/17, the following was noted:
a. a three inch by six inch hole was noted near an I beam in the 2 hour fire resistant rated attic smoke barrier wall above the cross corridor door set from 5 West to the Patient Access lobby.
b. a one foot hole for the passage of one six inch in diameter pipe below the catwalk was noted in the 2 hour fire resistant rated attic smoke barrier wall above the cross corridor door set near the west wall of the main entrance lobby.
Based on interview at the time of the observations, the Maintenance Supervisor and Maintenance Assistant acknowledged the aforementioned openings in two hour rated fire walls were not protected to limit the spread of fire for a time period equal to the fire resistance of the assembly.

2. Based on observation and interview, the facility failed to ensure 1 of 1 ceiling smoke barriers was maintained to provide at least a one half hour fire resistance rating. This deficient practice could affect 20 patients, staff and visitors.

Findings include:

Based on observations with the Chief Financial Officer (CFO) and the Maintenance Assistant during a tour of the facility from 10:20 a.m. to 2:50 p.m. on 05/30/17, the following openings were noted in the ceiling smoke barrier:
a. a two inch hole and a one inch hole in the 3 West Assessment Room.
b. a three inch hole for the passage of three conduits for the Electrical Room above the "EQ4" panel.
c. an eight inch hole in the computer room by the sprinkler riser room.
Based on interview at the time of the observations, the CFO and the Maintenance Assistant acknowledged the aforementioned holes in the ceiling smoke barrier did not 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 3 of 13 smoke barrier doors would restrict the movement of smoke for at least 20 minutes. This deficient practice affects 20 patients, staff and visitors.

Findings include:

Based on observations with the Chief Financial Officer (CFO), Maintenance Supervisor and the Maintenance Assistant during a tour of the facility from 10:20 a.m. to 2:50 p.m. on 05/30/17, the following was noted:
a. the set of corridor smoke barrier doors outside the Dining Room were each propped in the fully open position with a wedge placed on the floor.
b. a one inch in diameter hole was noted near the door latching mechanism in the smoke barrier door in the walk way leading to the Dining Room from 3 West and 4 West.
Based on interview at the time of the observations, the Maintenance Supervisor acknowledged the aforementioned corridor smoke barrier doors would not restrict the movement of smoke.

2. Based on observation and interview, the facility failed to ensure 1 of 2 Youth Hall sets of smoke barrier doors would restrict the movement of smoke for at least 20 minutes. LSC, Section 19.3.7.8 requires that doors in smoke barriers shall comply with LSC, Section 8.5.4. LSC, Section 8.5.4.1 requires doors in smoke barriers to close the opening leaving only the minimum clearance necessary for proper operation which is defined as 1/8 inch to restrict the movement of smoke. This deficient practice affects 12 patients who reside on the Youth Hall.

Findings include:

Based on observation on 05/30/17 at 1:25 p.m. with the director of plant operations, the Youth Hall south set of smoke barrier doors had a one inch gap along the edge of the doors where the doors came together in the closed position. This was verified by the director of plant operations at the time of observation and acknowledged by the chief executive officer at the exit conference on 05/30/17 at 3:00 p.m.

Based on record review and interview, the facility failed to provide 1 of 1 written emergency fire safety plan that incorporated all items listed in NFPA 101, Section 19.7.2.2.
1. Use of alarms.
2. Transmission of alarms to fire department.
3. Emergency phone call to fire department
4. Response to alarms.
5. Isolation of fire.
6. Evacuation of immediate area.
7. Evacuation of smoke compartment.
8. Preparation of floors and building for evacuation.
9. Extinguishment of fire.
This deficient practice affects all patients, staff and visitors in the event of an emergency.

Findings include:

Based on record review on 05/30/17 at 11:15 a.m. with the director of plant operations, the facility's fire safety plan labeled Emergency Operations Plan lacked the use of the fire alarm system by staff, the transmission of the alarms to the fire department, and extinguishment of fire including kitchen staff use of the K Class fire extinguisher in relationship to the overhead hood extinguishing system. This was verified by the director of plant operations at the time of record review and acknowledged by the chief executive officer at the exit conference on 05/30/17 at 3:00 p.m.

Based on observation and interview, the facility failure to ensure 1 of 1 portable space heaters used in nonsleeping staff and employee areas had heating elements which do not exceed 212 degrees Fahrenheit (100 degrees Celsius). This deficient practice could affect 5 staff and visitors in the vicinity of the 5 West office near the courtyard exit door.

Findings include:

Based on observations with the Chief Financial Officer (CFO) and the Maintenance Assistant during a tour of the facility from 10:20 a.m. to 2:50 p.m. on 05/30/17, an operable portable space heater was plugged into a power strip in the 5 West office near the courtyard exit door. Manufacturer's documentation affixed to the portable space heater did not state the maximum temperature achieved by the unit. Based on interview at the time of the observations, the CFO and the Maintenance Assistant stated they were unaware of the maximum temperature achieved by the unit and acknowledged documentation of the maximum temperature achieved by the aforementioned portable space heater was not available for review.

1. Based on observation and interview, the facility failed to ensure 1 of 2 emergency generators were kept in reliable operating mode in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 2010 Edition, Section 5.6.6 states a remote, common audible alarm shall be provided as specified in 5.6.5.2(4) that is powered by the storage battery and located outside of the (Emergency Power Supply) EPS service room at a work site observable by personnel. Section 8.3.1 states the Emergency Power Supply Systems (EPSS) shall be maintained to ensure that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class. This deficiency could affect all patients, staff and visitors.

Findings include:

Based on observations with the Chief Financial Officer (CFO) and the Maintenance Assistant during a tour of the facility from 10:20 a.m. to 2:50 p.m. on 05/30/17, the remote annunciator located at the 4 West and 5 West nurse's station for generator #1 failed failed to function when its respective test button was pushed five times. None of the safety indicator lights illuminated or functioned when the test buttons were pushed. Based on interview at time of the observations, the CFO acknowledged it could not be assured the remote annunciator was functional.

2. Based on record review and interview, the facility failed to maintain a complete written record of monthly generator load testing for 2 of 2 generators for 1 of the most recent 12 months. Chapter 6.4.4.1.1.4(A) of 2012 NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, Chapter 8. NFPA 110, Section 8.4.2 requires diesel generator sets in service to be exercised at least once monthly, for a minimum of 30 minutes. Chapter 6.4.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs for the generator to be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of the Monthly Generator Load Test Log documentation with the director of plant operations on 05/30/17 at 9:45 a.m., there was no documentation available for review to indicate a monthly load test was conducted for the month of December 2016 for Generator #1 and Generator #2. Based on interview at the time of record review, the director of plant operations indicated there was no record available for review to indicate a monthly load test was conducted on Generator #1 and Generator #2 for the month of December 2016. This was acknowledged by the chief executive officer at the exit conference on 05/30/17 at 3:00 p.m.

3. Based on record review and interview, the facility failed to ensure 2 of 2 emergency generators was allowed a 5 minute cool down period after monthly load tests for 12 of 12 months. Chapter 6.4.4.1.1.4(A) of 2012 NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, Chapter 8. NFPA 110, 2010 Edition, Section 6.2.10 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 shutdown. This delay provides additional engine cool down. This time delay shall not be required on small (15 kW or less) air-cooled prime movers. NFPA 110, Section 8.3.4 states a permanent record of the Emergency Power Supply Systems (EPSS) inspections, tests, exercising, operation, and repairs shall be maintained and readily available. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of the Monthly Generator Load Test Log documentation with the director of plant operations during record review from 9:45 a.m. to 10:10 a.m. on 05/30/17, documentation for monthly load tests conducted for the past twelve months for Generator #1 and Generator #2 did not include cool down time for each of the monthly load tests conducted. Based on interview at the time of record review, the director of plant operations stated the diesel fired emergency generators identified as Generator #1 and Generator #2 each have a 15 minute cool down time period following each monthly load test but acknowledged monthly load testing documentation did not include cool down time. The lack of documentation indicating a five minute cool down time after each monthly load test for Generator #1 and Generator #2 was verified by the director of plant operations at the time of record review and acknowledged by the chief executive officer at the exit conference on 05/30/17 at 3:00 p.m.

4. Based on observation and interview, the facility failed to ensure 1 of 2 emergency generator location was provided with a battery backup light in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition. NFPA 110, Chapter 7.3.1 requires the Level 1 or Level 2 EPS equipment location (s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observation on 05/30/17 at 11:35 a.m. with the director of plant operations, the Generator #2 emergency generator was located outside the maintenance shop in an enclosed fenced location. Furthermore, the enclosed location lacked a battery operated emergency light. This was verified by the director of plant operations at the time of observation and acknowledged by the chief executive officer at the exit conference on 05/30/17 at 3:00 p.m.

Based on record review, observation and interview; the facility failed to ensure 2 of 2 extension cords including power strips were not used as a substitute for fixed wiring. 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, 2011 Edition. NFPA 70, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice could affect five staff and visitors.

Findings include:

Based on observations with the Chief Financial Officer (CFO) and the Maintenance Assistant during a tour of the facility from 10:20 a.m. to 2:50 p.m. on 05/30/17, the following was noted:
a. a refrigerator and a microwave oven were plugged into a power strip in the Maintenance Office storage room. The UL listing of the power strip could not be determined.
b. a portable space heater was plugged into a power strip in the 5 West office by the courtyard exit door. The UL listing of the power strip could not be determined.
Based on interview at the time of the observations, the CFO and the Maintenance Assistant acknowledged a power strip was being used as a substitute for fixed wiring at the aforementioned locations.