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Based on record review and interview, the facility failed to ensure 1 of 1 kitchen range hood extinguishing system was maintained in proper working order. This deficient practice could affect all patients and staff.

Findings include:

Based on record review on 06/21/22 between 9:45 a.m. and 4:45 p.m. with the Facilities Manager present, range hood suppression reports dated 12/03/21 and 06/10/21 from the facility's vendor both stated "Exhaust Fan does not kick on upon System Activation". When asked, the Facilities Manager said after checking with the vendor it has not been fixed, but they are now scheduled to come fix the issue within the next week.

This finding was reviewed with the QI Director, Chief Clinical Officer, Chief Financial Officer, Facilities Manager, and Safety and Security Coordinator during the exit conference.

Based on observation and interview, the facility failed to ensure 2 of over 10 hard wired smoke detectors was not installed where air flow would adversely affect its operation. NFPA 72, 2010 edition, 17.7.6.3.2 requires that smoke detectors shall not be located directly in the airstream of supply registers. Section 17.7.4.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. A.17.7.4.1 states detectors should not be located in a direct airflow or closer than 36 inches from an air supply diffuser or return air opening. This deficient practice could affect at least 5 patients and staff.

Findings include:

Based on observations on 06/21/22 between 3:15 p.m. and 3:45 p.m. during a tour of the facility with the Safety and Security Coordinator, the following was noted:
a. There was a ceiling mounted smoke detector in the Building 281 Waiting Room within one foot of an air supply vent.
b. There was a ceiling mounted smoke detector in the Building 281 C.A.S.E. Waiting Room within one foot of an air supply vent.
Based on interview at the time of each observation, the Safety and Security Coordinator agreed the two smoke detectors were within one foot of the air supply vents.

This finding was reviewed with the QI Director, Chief Clinical Officer, Chief Financial Officer, Facilities Manager, and Safety and Security Coordinator during the exit conference.

Based on record review and interview, the facility failed to provide a complete written policy for the protection of all 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 occupants in the facility.

Findings include:

Based on record review on 06/21/22 between 9:45 a.m. and 4:45 p.m. with the Safety and Security Coordinator present, the facility provided fire watch documentation from the Emergency Preparedness Plan, however, it was incomplete. The plan did include the phone number for the IDOH, however, the plan failed to include contacting the Indiana Department of Health (IDOH) with the web link for contacting the Incident Reporting System located on the IDOH Gateway. Based on an interview at the time of record review, the Safety and Security Coordinator agreed the fire watch policy lacked the previously mentioned information.

This finding was reviewed with the QI Director, Chief Clinical Officer, Chief Financial Officer, Facilities Manager, and Safety and Security Coordinator during the exit conference.

Based on observation and interview, the facility failed to ensure the ceiling in 1 of 2 sprinklered smoke compartments was maintained to allow sprinkler heads to function to their full capability. This deficient practice could affect all patients and staff.

Findings include:

Based on observations on 06/21/22 between 2:30 p.m. and 3:10 p.m. during a tour of the facility with the Safety and Security Coordinator, the following was noted:
a. There were two ceiling tiles missing in the sprinklered Janitorial Closet
b. There were two ceiling tiles missing in the sprinklered Supply Closet
Based on interview at the time of each observation, the Safety and Security Coordinator agreed there were missing ceiling tiles in the Janitorial Closet and Supply Closet.

This finding was reviewed with the QI Director, Chief Clinical Officer, Chief Financial Officer, Facilities Manager, and Safety and Security Coordinator during the exit conference.

Based on observation and interview, the facility failed to ensure 1 of over 5 wet locations, was provided with ground fault circuit interrupter (GFCI) protection against electric shock. NFPA 70, NEC 2011 Edition at 210.8 Ground-Fault Circuit-Interrupter Protection for Personnel, states, ground-fault circuit-interruption for personnel shall be provided as required in 210.8(A) through (C). The ground-fault circuit-interrupter shall be installed in a readily accessible location.
Informational Note: See 215.9 for ground-fault circuit interrupter protection for personnel on feeders.
(B) Other Than Dwelling Units. All 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified in 210.8(B)(1) through (8) shall have ground-fault circuit-interrupter protection for personnel.
(1) Bathrooms
(2) Kitchens
(3) Rooftops
(4) Outdoors
Exception No. 1 to (3) and (4): Receptacles that are not readily accessible and are supplied by a branch circuit dedicated to electric snow-melting, deicing, or pipeline and vessel heating equipment shall be permitted to be installed in accordance with 426.28 or 427.22, as applicable.
Exception No. 2 to (4): In industrial establishments only, where the conditions of maintenance and supervision ensure that only qualified personnel are involved, an assured equipment grounding conductor program as specified in 590.6(B)(2) shall be permitted for only those receptacle outlets used to supply equipment that would create a greater hazard if power is interrupted or having a design that is not compatible with GFCI protection.
(5) Sinks - where receptacles are installed within 1.8 m (6 ft.) of the outside edge of the sink.
Exception No. 1 to (5): In industrial laboratories, receptacles used to supply equipment where removal of power would introduce a greater hazard shall be permitted to be installed without GFCI protection.
Exception No. 2 to (5): For receptacles located in patient bed locations of general care or critical care areas of health care facilities other than those covered under
210.8(B)(1), GFCI protection shall not be required.
(6) Indoor wet locations
(7) Locker rooms with associated showering facilities
(8) Garages, service bays, and similar areas where electrical
diagnostic equipment, electrical hand tools.
NFPA 70, 517-20 Wet Locations, requires all receptacles and fixed equipment within the area of the wet location to have ground-fault circuit interrupter (GFCI) protection. Note: Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice could affect patients and staff.

Findings include:

Based on observations on 06/21/22 between 2:30 p.m. and 3:10 p.m. during a tour of the facility with the Safety and Security Coordinator, two electric receptacles within two feet of the counter sink in the kitchen/dining room area were not provided with properly working GFCI protection. The receptacle to the left of the sink was provided with a GFCI receptacle, however, when tested with a GFCI testing device, it did not break the circuit. The testing device showed the wiring to be correct. Furthermore, the circuit did not break when attempting to use the test button on the receptacle. The receptacle to the right of the sink was not provided with a GFCI receptacle. When tested with a GFCI testing device, it did not break the circuit. Based on interview at the time of each observation, the Safety and Security Coordinator agreed the previously mentioned receptacles were not GFCI protected.

This finding was reviewed with the QI Director, Chief Clinical Officer, Chief Financial Officer, Facilities Manager, and Safety and Security Coordinator during the exit conference.

Based on record review and interview, the facility failed to maintain a complete written record of monthly generator load testing for 2 of 2 generator during 12 of the past 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. 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. Chapter 6-4.4.1.3 of 2012 NFPA 99 requires batteries for on-site generators shall be maintained in accordance with NFPA 110, 2010 Edition, Standard for Emergency and Standby Power Systems. 8.3.7 requires storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications. 8.3.7.2 states defective batteries shall be repaired or replaced immediately upon discovery of defects. Chapter 6.5.4.2 of NFPA 99 requires a written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. This deficient practice could affect all occupants.

Findings include:

Based on record review on 06/21/22 between 9:45 a.m. and 4:45 p.m. with the Facilities Manager present, there was no monthly generator load test documentation available during the past 12 months. Based on interview at the time of record review, the Facilities Manager said the facility's generator power comes from the main hospital next door. He further said maintenance staff from the main hospital was unavailable to provide the monthly generator load testing documentation.

This finding was reviewed with the QI Director, Chief Clinical Officer, Chief Financial Officer, Facilities Manager, and Safety and Security Coordinator during the exit conference.