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Based on observation and interview, the facility failed to ensure 1 of 1 outpatient reception offices open to the corridor was provided with an electrically supervised automatic smoke detection system. Exception No. 1 to LSC Section 19.3.6.1 states smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.3 shall be permitted to have spaces 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 in accordance with 19.3.4 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 in accordance with 19.3.4 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 access.
This deficient practice could affect one patient, staff and visitors near the Outpatient Reception Office.

Findings include:

Based on observations with the Director of Plant Operations during a tour of the facility from 1:30 p.m. to 3:15 p.m. on 04/25/16, the Outpatient Reception Office was not provided with an electrically supervised automatic smoke detection system and is open to the corridor because the adjoining Outpatient waiting area is open to the corridor. The Outpatient Reception Office is open to the corridor because the adjoining Outpatient waiting area has no corridor door and a three foot by four foot wide set of nonrated sliding glass doors was in the separation wall of the reception office from the waiting area. The automatic sprinkler system observed in the reception office was not equipped with quick response sprinklers and is not arranged and located to allow continuous direct supervision by the facility staff from a nurses' station or similar space. Based on interview at the time of the observations, the Director of Plant Operations stated outpatients have customary access to the waiting area and acknowledged the Outpatient Reception Office area is open to the corridor and is not provided with an electrically supervised automatic smoke detection system.

Based on observation and interview, the facility failed to ensure 3 of 8 exit accesses were provided with handrails. LSC 7.2.2.4.2 requires stairs and ramps shall have handrails on both sides. In addition, handrails shall be provided within 30 inches of all portions of the required egress width of stairs. The required egress width shall be provided along the natural path of travel. This deficient practice could affect 20 patients, staff and visitors if needing to exit the facility.

Findings include:

Based on observations with the Director of Plant Operations during a tour of the facility from 1:30 p.m. to 3:15 p.m. on 04/25/16, the Dining Room exit discharge, Outpatient corridor exit discharge and the south exit discharge each led to the public way and had a portion of the exit discharge constructed as a ramp. The Outpatient exit discharge had a twenty foot sloping ramp sidewalk section with a twelve inch rise over the length of the ramp which was not provided with handrails. The Dining Room exit discharge had a fifteen foot sloping ramp sidewalk section with a sixteen inch rise over the length of the ramp which was not provided with handrails. The south exit discharge had a ten foot sloping ramp sidewalk section with a one foot rise over the length of the ramp which was not provided with handrails. Based on interview at the time of the observations, the Director of Plant Operations acknowledged the aforementioned three exit discharge ramps to the public way were not provided with handrails.

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 1 of 1 written fire safety plans for the facility in the event of an emergency. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to the fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
This deficient practice could affect three staff and visitors in the kitchen.

Findings include:

Based on review of "Emergency Operations Plan: Fire Plan" documentation with the Director of Plant Operations during record review from 10:40 a.m. to 12:45 p.m. on 04/25/16, the written fire safety plan 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 record review, the Director of Plant Operations acknowledged the written fire safety plan 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 Director of Plant Operations during a tour of the facility from 1:30 p.m. to 3:15 p.m. on 04/25/16, a portable K Class fire extinguisher was located in the kitchen and a placard was 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 document activation of the fire alarm system for first and second shift fire drills conducted between 6:00 a.m. and 9:00 p.m. for 3 of 4 quarters. LSC 19.7.1.2 states fire drills in health care occupancies shall include the transmission of the fire alarm signal and simulation of emergency fire conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Fire Drill Report" and "Bloomington Hospital - Healthcare Peer Review Report" documentation with the Director of Plant Operations during record review from 10:40 a.m. to 12:45 p.m. on 04/25/16, the following was noted:
a. documentation for first shift fire drills conducted on 12/17/15 at 10:00 a.m. and on 02/23/16 at 9:30 a.m. did not include activation of the fire alarm system and transmission of the fire alarm signal. The aforementioned first shift fire drill documentation stated, respectively, "Simulated" and "Drill was simulated."
b. documentation for the second shift fire drill conducted on 04/08/15 at 4:00 p.m. did not include activation of the fire alarm system and transmission of the fire alarm signal. The aforementioned second shift fire drill documentation stated "simulated grease fire."
Based on interview at the time of record review, the Director of Plant Operations acknowledged documentation for the aforementioned first and second shift fire drills conducted after 6:00 a.m. but before 9:00 p.m. did not include activation of the fire alarm system and transmission of the fire alarm signal.

Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with a remote manual stop. LSC 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 1999 edition, 3-5.5.6 requires Level II installations shall have a remote manual stop station of a type similar to a break-glass station located elsewhere on the premises where the prime mover is located outside the building. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for shutting down the engine at the engine and from a remote location. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observation with the Director of Plant Operations during a tour of the facility from 1:30 p.m. to 3:15 p.m. on 04/25/16, the emergency generator lacked a remote shut off device. Manufacturer's documentation affixed to the emergency generator indicated it was rated at 150 kW. Based on interview at the time of observation, the Director of Plant Operations acknowledged the emergency generator was rated over 100 horsepower and verified there was no remote shut off device for the emergency generator.

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 35 of 35 residents. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, 1998 Edition, the Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 11-5(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 "Emergency Operations Plan: Fire Watch" and "Fire Alarm Disruptions" documentation with the Director of Plant Operations during record review from 10:40 a.m. to 12:45 p.m. on 04/25/16, 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 the authority having jurisdiction and the building owner. Based on interview at the time of record review, the Director of Plant Operations acknowledged 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 ISDH and the building owner.

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 35 of 35 residents. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Emergency Operations Plan: Fire Watch" and "Fire Alarm Disruptions" documentation with the Director of Plant Operations during record review from 10:40 a.m. to 12:45 p.m. on 04/25/16, the written fire watch policy 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 the Indiana State Department of Health (ISDH) which is an authority having jurisdiction. Based on interview at the time of record review, the Director of Plant Operations acknowledged the written fire watch policy 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.

Based on observation and interview, the facility failed to ensure 1 of 1 outpatient reception offices open to the corridor was provided with an electrically supervised automatic smoke detection system. Exception No. 1 to LSC Section 19.3.6.1 states smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.3 shall be permitted to have spaces 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 in accordance with 19.3.4 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 in accordance with 19.3.4 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 access.
This deficient practice could affect one patient, staff and visitors near the Outpatient Reception Office.

Findings include:

Based on observations with the Director of Plant Operations during a tour of the facility from 1:30 p.m. to 3:15 p.m. on 04/25/16, the Outpatient Reception Office was not provided with an electrically supervised automatic smoke detection system and is open to the corridor because the adjoining Outpatient waiting area is open to the corridor. The Outpatient Reception Office is open to the corridor because the adjoining Outpatient waiting area has no corridor door and a three foot by four foot wide set of nonrated sliding glass doors was in the separation wall of the reception office from the waiting area. The automatic sprinkler system observed in the reception office was not equipped with quick response sprinklers and is not arranged and located to allow continuous direct supervision by the facility staff from a nurses' station or similar space. Based on interview at the time of the observations, the Director of Plant Operations stated outpatients have customary access to the waiting area and acknowledged the Outpatient Reception Office area is open to the corridor and is not provided with an electrically supervised automatic smoke detection system.

Based on observation and interview, the facility failed to ensure 3 of 8 exit accesses were provided with handrails. LSC 7.2.2.4.2 requires stairs and ramps shall have handrails on both sides. In addition, handrails shall be provided within 30 inches of all portions of the required egress width of stairs. The required egress width shall be provided along the natural path of travel. This deficient practice could affect 20 patients, staff and visitors if needing to exit the facility.

Findings include:

Based on observations with the Director of Plant Operations during a tour of the facility from 1:30 p.m. to 3:15 p.m. on 04/25/16, the Dining Room exit discharge, Outpatient corridor exit discharge and the south exit discharge each led to the public way and had a portion of the exit discharge constructed as a ramp. The Outpatient exit discharge had a twenty foot sloping ramp sidewalk section with a twelve inch rise over the length of the ramp which was not provided with handrails. The Dining Room exit discharge had a fifteen foot sloping ramp sidewalk section with a sixteen inch rise over the length of the ramp which was not provided with handrails. The south exit discharge had a ten foot sloping ramp sidewalk section with a one foot rise over the length of the ramp which was not provided with handrails. Based on interview at the time of the observations, the Director of Plant Operations acknowledged the aforementioned three exit discharge ramps to the public way were not provided with handrails.

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 1 of 1 written fire safety plans for the facility in the event of an emergency. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to the fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
This deficient practice could affect three staff and visitors in the kitchen.

Findings include:

Based on review of "Emergency Operations Plan: Fire Plan" documentation with the Director of Plant Operations during record review from 10:40 a.m. to 12:45 p.m. on 04/25/16, the written fire safety plan 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 record review, the Director of Plant Operations acknowledged the written fire safety plan 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 Director of Plant Operations during a tour of the facility from 1:30 p.m. to 3:15 p.m. on 04/25/16, a portable K Class fire extinguisher was located in the kitchen and a placard was 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 document activation of the fire alarm system for first and second shift fire drills conducted between 6:00 a.m. and 9:00 p.m. for 3 of 4 quarters. LSC 19.7.1.2 states fire drills in health care occupancies shall include the transmission of the fire alarm signal and simulation of emergency fire conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Fire Drill Report" and "Bloomington Hospital - Healthcare Peer Review Report" documentation with the Director of Plant Operations during record review from 10:40 a.m. to 12:45 p.m. on 04/25/16, the following was noted:
a. documentation for first shift fire drills conducted on 12/17/15 at 10:00 a.m. and on 02/23/16 at 9:30 a.m. did not include activation of the fire alarm system and transmission of the fire alarm signal. The aforementioned first shift fire drill documentation stated, respectively, "Simulated" and "Drill was simulated."
b. documentation for the second shift fire drill conducted on 04/08/15 at 4:00 p.m. did not include activation of the fire alarm system and transmission of the fire alarm signal. The aforementioned second shift fire drill documentation stated "simulated grease fire."
Based on interview at the time of record review, the Director of Plant Operations acknowledged documentation for the aforementioned first and second shift fire drills conducted after 6:00 a.m. but before 9:00 p.m. did not include activation of the fire alarm system and transmission of the fire alarm signal.

Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with a remote manual stop. LSC 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 1999 edition, 3-5.5.6 requires Level II installations shall have a remote manual stop station of a type similar to a break-glass station located elsewhere on the premises where the prime mover is located outside the building. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for shutting down the engine at the engine and from a remote location. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observation with the Director of Plant Operations during a tour of the facility from 1:30 p.m. to 3:15 p.m. on 04/25/16, the emergency generator lacked a remote shut off device. Manufacturer's documentation affixed to the emergency generator indicated it was rated at 150 kW. Based on interview at the time of observation, the Director of Plant Operations acknowledged the emergency generator was rated over 100 horsepower and verified there was no remote shut off device for the emergency generator.

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 35 of 35 residents. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, 1998 Edition, the Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 11-5(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 "Emergency Operations Plan: Fire Watch" and "Fire Alarm Disruptions" documentation with the Director of Plant Operations during record review from 10:40 a.m. to 12:45 p.m. on 04/25/16, 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 the authority having jurisdiction and the building owner. Based on interview at the time of record review, the Director of Plant Operations acknowledged 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 ISDH and the building owner.

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 35 of 35 residents. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Emergency Operations Plan: Fire Watch" and "Fire Alarm Disruptions" documentation with the Director of Plant Operations during record review from 10:40 a.m. to 12:45 p.m. on 04/25/16, the written fire watch policy 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 the Indiana State Department of Health (ISDH) which is an authority having jurisdiction. Based on interview at the time of record review, the Director of Plant Operations acknowledged the written fire watch policy 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.