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Based on observation and interview, the facility failed to ensure the penetration in 1 of 6 fire barrier floor/ceiling assemblies was maintained to ensure the fire resistance of the barrier. LSC 19.1.1.3 requires all health care facilities to be maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of the occupants. LSC 8.3.5.1 requires penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Fire Stops. This deficient practice could affect staff on the 5th Floor and patients, visitors and staff on the 4th Floor.

Findings include:

During a tour of the facility with the Vice President Administrative Services, Facility Manager, Manager of Biomedical Engineering, and Director of Security on 11/12/19 at 1:46 p.m. two unsealed stubbed four-inch conduits penetrated the two-hour rated floor ceiling assembly between the 5th Floor, which is a Business Occupancy, and the 4th Floor, which is a Healthcare Occupancy. Based on interview at the time of observation, the Facility Manager agreed that the conduits penetrated the floor/ceiling assembly which separated the 5th Floor from the 4th Floor.

Based on record review, observation and interview, the facility to maintain the limited noncombustible rating in accordance with LSC Table 19.1.6.1. This deficient practice could affect all occupants.

Findings include:

During record review with the Facility Manager on 11/13/19 between 11:00 a.m. and 12:00 p.m., the Life Safety Plans indicated the 5th Floor "Interstitial Space" was constructed to I (332) rating. During a subsequent tour of the 5th floor on the same date, the following were observed:
a) At 1:41 p.m. a steel support beam above an air handler unit had a location measuring approximately four inches by four inches where the protective coating was removed. Based on an interview at the time of observation, the Facility Manager agreed that protective coating had been removed.
b) At 1:51 p.m. 2 cross braces were found to be missing the protective coating. The remaining visible cross braces were protected by a protective coating. Based on interview at the time of observation, the Facility Manager agreed that two cross-braces were missing the protective coating.

Based on observation and interview, the facility failed to ensure 1 of 1 "OR Supply Room" door was only held open by a release device complying with LSC 7.2.1.8.2 that automatically closes such doors upon activation of the fire alarm system. This deficient practice could affect any occupant using the central exit enclosure.

Findings include:

During a tour of the facility with the Facility Manager on 11/13/19 at 1:35 p.m. the corridor door which lead from the "OR Supply Room" to the central exit enclosure was held open by a rubber wedge. The door was equipped with a self-closing device and was located in a barrier wall with a 2-hour Fire Resistive Rating, which protected the central exit enclosure. Based on interview at the time of observation, the Facility Manager agreed that the door was propped open with a rubber wedge, which would not release with the fire alarm. It was noted that this was corrected prior to exit.

Based on observation and interview, the facility failed to meet 1 of multiple corridors clear width requirement exception per 19.2.3.4(1). LSC 19.2.3.4(1) requires aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall not be less than 44 inches in clear and unobstructed width. This deficient practice could affect staff only.

Findings include:

During a facility tour with the Vice President Administrative Services, Director of Engineering and Maintenance, Facility Manager, Manager of Biomedical Engineering, and Director of Security on 11/12/19 at 3:20 p.m. the clear width of the east corridor of the West 2nd Floor was not maintained. At the time of survey, the West 2nd Floor was not being utilized for the treatment or care of patients. The pharmacy staff had temporarily used the space to set up new electronic medication dispensing units. The units were kept in the corridor, leaving a clear width of 35 inches. This was confirmed by the Director of Engineering and Maintenance at the time of observation. It was noted that this was corrected prior to the exit on 11/14/19.

1. Based on record review, observation and interview; the facility failed to document monthly and annual testing for all battery backup lights in accordance with LSC 7.9. Section 7.9.3.1.1 states testing of emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2) The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the tests required by 7.9.3.1.1(1) and (3).
(5) 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 "Building and Grounds Checklist" documentation with the Manager of Engineering Maintenance, Director of Engineering & Facilities and the Security Manager during record review from 10:00 a.m. to 2:50 p.m. on 11/13/19, monthly and annual functional testing documentation itemized by location for all battery backup lights was not available for review. The aforementioned documentation listed a monthly check for all "Emergency Lights" for the 9 month period of January 2019 through September 2019 but it did not list the location of each light and the duration of the test. Based on interview at the time of record review, the Manager of Engineering Maintenance stated the facility documents a monthly check for all battery backup lights in the facility but it is not itemized by location and the check does not include if it is a monthly check for 30 seconds or an annual check for 90 minutes. Based on observations with the Director of Engineering & Facilities during a tour of the facility from 8:30 a.m. to 10:20 a.m. on 11/14/19, 17 battery operated lighting systems were located in the facility and each lighting system functioned when its respective test button was pushed except for five lights.

2. Based on observation and interview, the facility failed to ensure 5 of 17 battery powered emergency lights was 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. This deficient practice could affect over 5 patients, staff and visitors.

Findings include:

Based on observations with the Director of Engineering & Facilities and the Manager for Outpatient Therapy during a tour of the facility from 8:30 a.m. to 10:20 a.m. on 11/14/19, the following battery powered emergency light locations failed to illuminate when its respective test button was pushed multiple times:
a. by the entrance to outpatient area.
b. by the patient lockers.
c. by the washer and dryer closet by Hydrotherapy.
d. by the stairwell.
e. by the Data Room by the office area.
Based on interview at the time of the observations, the Director of Engineering & Facilities agreed the aforementioned battery powered emergency lights each failed to illuminate when its respective test button was pushed multiple times and had building maintenance staff replace the lighting systems at the time of the observations.

1. Based on record review, observation and interview; the facility failed to document monthly and annual testing for all battery backup lights in accordance with LSC 7.9. Section 7.9.3.1.1 states testing of emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2) The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the tests required by 7.9.3.1.1(1) and (3).
(5) 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 "Building and Grounds Checklist" documentation with the Manager of Engineering Maintenance, Director of Engineering & Facilities and the Security Manager during record review from 10:00 a.m. to 2:50 p.m. on 11/13/19, monthly and annual functional testing documentation itemized by location for all battery backup lights was not available for review. The aforementioned documentation listed a monthly check for all "Emergency Lights" for the 9 month period of January 2019 through September 2019 but it did not list the location of each light and the duration of the test. Based on interview at the time of record review, the Manager of Engineering Maintenance stated the facility documents a monthly check for all battery backup lights in the facility but it is not itemized by location and the check does not include if it is a monthly check for 30 seconds or an annual check for 90 minutes. Based on observations with the Director of Engineering & Facilities during a tour of the facility from 8:30 a.m. to 10:20 a.m. on 11/14/19, 21 battery operated lighting systems were located in the facility and each lighting system functioned when its respective test button was pushed except for seven lights.

2. Based on observation and interview, the facility failed to ensure 7 of 21 battery powered emergency lights was 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. This deficient practice could affect over 10 patients, staff and visitors.

Findings include:

Based on observations with the Director of Engineering & Facilities and the X-Ray Technician for Diagnostic Imaging during a tour of the facility from 8:30 a.m. to 10:20 a.m. on 11/14/19, the following battery powered emergency light locations failed to illuminate when its respective test button was pushed multiple times:
a. by the Clean Room.
b. in the Mechanical Room by the Clean Room.
c. by the Changing Room.
d. by the MRI Unit.
e. by Radiology.
f. by the CAT Scan Change Room.
g. in the Automatic Transfer Switch room.
Based on interview at the time of the observations, the Director of Engineering & Facilities agreed the aforementioned battery powered emergency lights each failed to illuminate when its respective test button was pushed multiple times and had building maintenance staff replace the lighting systems at the time of the observations.

Based on record review, observation and interview; the facility failed to document monthly and annual testing for all battery backup lights in accordance with LSC 7.9. Section 7.9.3.1.1 states testing of emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2) The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the tests required by 7.9.3.1.1(1) and (3).
(5) 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 two patients, staff and visitors.

Findings include:

Based on review of "Building and Grounds Checklist" documentation with the Manager of Engineering Maintenance, Director of Engineering & Facilities and the Security Manager during record review from 10:00 a.m. to 2:50 p.m. on 11/13/19, monthly and annual functional testing documentation itemized by location for all battery backup lights was not available for review. The aforementioned documentation listed a monthly check for all "Emergency Lights" for the 9 month period of January 2019 through September 2019 but it did not list the location of each light and the duration of the test. Based on interview at the time of record review, the Manager of Engineering Maintenance stated the facility documents a monthly check for all battery backup lights in the facility but it is not itemized by location and the check does not include if it is a monthly check for 30 seconds or an annual check for 90 minutes. Based on observations with the Director of Engineering & Facilities and the Purchasing Manager for the Surgery Center during a tour of the facility from 8:30 a.m. to 10:20 a.m. on 11/14/19, the facility has two procedure rooms. Lighting systems on normal power installed on the ceiling of each procedure room appeared to have battery backup power and illuminated by red test buttons but the surveyor was unable to test the lighting systems due to the lack of a ladder. Based on interview at the time of the observations, the Director of Engineering & Facilities agreed it could not be assured the two procedure rooms were provided with battery-powered lighting units tested on a monthly and annual basis.

Based on record review, observation and interview; the facility failed to ensure emergency lighting in 4 of 4 operating rooms where general anesthesia is administered were installed and tested in accordance with NFPA 99. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 6.3.2.2.11.1 states one or more battery-powered lighting units shall be provided within locations where deep sedation and general anesthesia is administered. The lighting level of each unit shall be sufficient to terminate procedures intended to be performed within the operating room. The sensor for units shall be wired to the branch circuit(s) serving general lighting within the room. Units shall be capable of providing lighting for 90 minutes and shall be tested monthly for 30 seconds and annually for 30 minutes. Section 3.3.17 defines battery-powered lighting units as individual unit equipment for backup illumination consisting of a rechargeable battery, battery-charging means, provisions for one or more lamps mounted on the equipment, or with terminals for remote lamps, or both, and relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment. This deficient practice could affect four patients and staff in operating rooms where general anesthesia or life support equipment is used.

Findings include:

Based on the interview during the entrance conference at 10:00 a.m. on 11/13/19, the Vice President stated the surgery center has four operating rooms and general anesthesia is used in each of the four operating rooms. Based on review of "Building and Grounds Checklist" documentation with the Manager of Engineering Maintenance, Director of Engineering & Facilities and the Security Manager during record review from 10:00 a.m. to 2:50 p.m. on 11/13/19, monthly and annual functional testing documentation itemized by location for all battery backup lights was not available for review. The aforementioned documentation listed a monthly check for all "Emergency Lights" for the 9 month period of January 2019 through September 2019 but it did not list the location of each light and the duration of the test. Based on interview at the time of record review, the Manager of Engineering Maintenance stated the facility documents a monthly check for all battery backup lights in the facility but it is not itemized by location and the check does not include if it is a monthly check for 30 seconds or an annual check. Based on observations with the Director of Engineering & Facilities and the Purchasing Manager for the Surgery Center during a tour of the facility from 8:30 a.m. to 10:20 a.m. on 11/14/19, the facility has four operating rooms. Lighting systems on normal power installed on the ceiling of each operating room appeared to have battery backup power and illuminated by red test buttons but the surveyor was unable to test the lighting systems due to the lack of a ladder. Based on interview at the time of the observation, the Purchasing Manager for the Surgery Center agreed it could not be assured the four operating rooms where general anesthesia is administered were provided with battery-powered lighting units tested on a monthly and annual basis.

Based on observation and interview, the facility failed to ensure 1 of 2 basement stairwells were provided with a complete interior finish with a flame spread rating of Class A or Class B for a sprinklered facility. LSC 10.2.3.4 states products required to be tested in accordance with ASTM E 84, Standard Test Method for Surface Burning Characteristics of Building Materials or ANSI/UL 723, Standard for Test for Surface Burning Characteristics of Building Materials shall be grouped in the following classes in accordance with their flame spread and smoke development.
(a) Class A Interior Wall and Ceiling Finish. Flame spread 0-25; smoke development 0-450. Includes any material classified at 25 or less on the flame spread test scale and 450 or less on the smoke test scale. Any element thereof, when so tested, shall not continue to propagate fire.
(b) Class B Interior Wall and Ceiling Finish. Flame spread 26-75; smoke development 0-450. Includes any material classified at more than 25 but not more than 75 on the flame spread test scale and 450 or less on the smoke test scale.
(c) Class C Interior Wall and Ceiling Finish. Flame spread 76-200; smoke development 0-450. Includes any material classified at more than 75 but not more than 200 on the flame spread test scale and 450 or less on the smoke test scale.
This deficient practice could affect over 10 patients, staff and visitors.

Findings include:

Based on observations with the Director of Engineering & Facilities during a tour of the facility from 3:35 p.m. to 4:00 p.m. on 11/13/19, exposed wood studs and wood paneling was noted above the door frame for the door set to the A Basement stairwell. Interior finish flame spread rating documentation was not affixed to the exposed wood by the manufacturer. Based on interview at the time of the observations, the Director of Engineering & Facilities agreed interior finish flame spread rating documentation for the exposed wood interior finish was not available for review.

Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 19.3.4.1. NFPA 72, 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. This deficient practice could affect staff only in the Blood Lab.

Findings include:

Based on observation with the Facilities Manager on 11/14/19 at 10:26 a.m., the Blood Lab had two smoke detectors approximately 22 inches from an air duct. Based on interview at the time of the observation, the Facilities Manager acknowledged the smoke detectors as being within the 36 inch allowable minimum distance from an air inlet/outlet.

Based on record review and interview, the facility failed to provide a complete 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 could affect all patients, staff, and visitors.

Findings include:

Based on review of "Alternate Life Safety Measures" and "Fire Alarm Device Disablement During Construction Policy" documentation with the Manager of Engineering Maintenance, Director of Engineering & Facilities and the Security Manager during record review from 10:00 a.m. to 2:50 p.m. on 11/13/19, the fire watch policy for fire alarm system impairment was incomplete. The plan failed to include contacting the Indiana State Department of Health which is an authority having jurisdiction. Based on interview at the time of record review, the Manager of Engineering Maintenance agreed the fire watch documentation for fire alarm system impairment did not state to contact the Indiana State Department of Health.

Based on observation and interview, the facility failed to maintain the ceiling construction in 1 of 1 Maintenance Plans Room in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, 2010 edition, Section 6.2.7.1 states plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic, or shall be listed for use around a sprinkler. This deficient practice could affect staff only.

Findings include:

During a tour of the facility with the Facility Manager on 11/13/19 at 3:51 p.m. the sprinkler in the Maintenance Plans Room was missing an escutcheon. Based on interview at the time of observation, the Facility Manager agreed the escutcheon was missing. It was noted that this was corrected prior to the exit from the facility on 11/14/19.

1. Based on record review, observation and interview; the facility failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 3 of 4 quarters. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this Code be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 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 review of the sprinkler system contractor's "Sprinkler Inspection Certificate for Franciscan Point" documentation dated 10/22/19 with the Manager of Engineering Maintenance, Director of Engineering & Facilities and the Security Manager during record review from 10:00 a.m. to 2:50 p.m. on 11/13/19, quarterly waterflow alarm device inspection and testing documentation for the first quarter (January, February, March) 2019, second quarter (April, May, June) 2019 and third quarter (July, August, September) 2019 was not available for review. Based on interview at the time of record review, the Manager of Engineering Maintenance stated the facility has wet sprinkler systems, sprinkler system inspection and testing is performed by a contractor, the facility just changed to quarterly contractor inspection and testing and agreed documentation of sprinkler system inspection and testing for three of the most recent four calendar quarters was not available for review. Based on observations with the Director of Engineering & Facilities and the Purchasing Manager for the Surgery Center during a tour of the facility from 8:30 a.m. to 10:20 a.m. on 11/14/19, the facility has a supervised wet sprinkler system, the sprinkler system contractor had affixed a hanging tag to the sprinkler system riser documenting only one inspection was performed within the most recent twelve month period on 10/22/19.

2. Based on record review, observation and interview; the facility failed to document sprinkler system inspections in accordance with NFPA 25. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 5.1.2 states valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 13. Section 13.1.1.2 states Table 13.1.1.2 shall be utilized for inspection, testing and maintenance of valves, valve components and trim. Section 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all patients, staff, and visitors.

Findings include:

Based on review of the sprinkler system contractor's "Sprinkler Inspection Certificate for Franciscan Point" documentation dated 10/22/19 with the Manager of Engineering Maintenance, Director of Engineering & Facilities and the Security Manager during record review from 10:00 a.m. to 2:50 p.m. on 11/13/19, monthly wet sprinkler system gauge inspection documentation for 11 months of the most recent 12 month period was not available for review. In addition, monthly inspection documentation for all sprinkler system control valves for 11 months of the most recent 12 month period was not available for review. Based on interview at the time of record review, the Manager of Engineering Maintenance stated the facility has wet sprinkler systems and the facility does not perform and document sprinkler system gauge and valve inspections outside of the contractor's inspections. Based on observations with the Director of Engineering & Facilities and the Purchasing Manager for the Surgery Center during a tour of the facility from 8:30 a.m. to 10:20 a.m. on 11/14/19, the facility has a supervised wet sprinkler system, the sprinkler system contractor had affixed a hanging tag to the sprinkler system riser documenting only one inspection was performed within the most recent twelve month period on 10/22/19.

Based on observation and interview, the facility failed to ensure 1 of over 200 sprinkler heads were replaced in accordance with NFPA 25. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.1.1.1 states sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., up-right, pendent, or sidewall). Furthermore, at 5.2.1.1.2 any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical Damage
(4) Loss of fluid in the glass bulb heat responsive element
(5) Loading
(6) Painting unless painted by the sprinkler manufacturer.
In lieu of replacing sprinklers that are loaded with dust, it is permitted to clean sprinklers with compressed air or by a vacuum provided that the equipment does not touch the sprinkler.
This deficient practice could affect over 10 patients, staff and visitors.

Findings include:

Based on observations with the Director of Engineering & Facilities during a tour of the facility from 3:35 p.m. to 4:00 p.m. on 11/13/19, the sprinkler head located above the stairwell to the A Basement was loaded with spackling compound. Based on interview at the time of the observations, the Director of Engineering & Facilities agreed the aforementioned automatic sprinkler was loaded with a foreign material.



36620

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 1 of 4 quarters. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this Code be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 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 review of the quarterly sprinkler system inspection records on 11/13/19 at 11:27 a.m. with the Manager of Engineering / Maintenance present, there was no quarterly sprinkler system inspection report available for the first quarter (January, February, and March) of 2019. During an interview at the time of record review, the Manager of Engineering / Maintenance acknowledged there was no written documentation available to show the sprinkler system had been inspected during the first quarter of 2019.


38900

Based on observation and interview, the facility failed to maintain 1 of 1 sprinkler system in accordance with LSC Section 9.7.5. Section 9.7.5 states that all automatic sprinkler and standpipe systems required by this code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 edition, 5.2.2.2 requires sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe. This deficient practice could affect all occupants.

Findings include:

During a facility tour with the Vice President Administrative Services, Director of Engineering and Maintenance, and Facility Manager, on 11/12/19 at 1:33 p.m., it was observed that electrical flex coil was supported by sprinkler pipe above the lay-in suspended ceiling in front of room 623. Based on interview at the time of observation, the Facility Manager confirmed that electrical flex coil was supported by the sprinkler pipe. It was noted that this was corrected prior to the exit from the facility on 11/14/19.

Based on record review and interview, the facility failed to provide a complete written policy containing procedures to be followed for the protection of all patients 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, 2011 Edition, Section 15.5.2 requires the fire department, insurance carrier, the alarm company, the property owner or designated representative and other authorities having jurisdiction be notified. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of "Alternate Life Safety Measures" and "Fire Alarm Device Disablement During Construction Policy" documentation with the Manager of Engineering Maintenance, Director of Engineering & Facilities and the Security Manager during record review from 10:00 a.m. to 2:50 p.m. on 11/13/19, the fire watch policy for automatic sprinkler system impairment was incomplete. The plan failed to include contacting the Indiana State Department of Health which is an authority having jurisdiction. Based on interview at the time of record review, the Manager of Engineering Maintenance agreed the fire watch documentation for automatic sprinkler system impairment did not state to contact the Indiana State Department of Health.

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. NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition, Section 5.5.5 states fire extinguishers provided for the protection of cooking appliances using combustible cooking media (vegetable or animal oils and fats) shall be listed and labeled for Class K fires. NFPA 10, 5.5.5.3 states a placard shall be placed near the extinguisher that states that the protection system shall be actuated 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 the portable fire extinguisher. In this instance, the portable fire extinguisher is supplemental protection. This deficient practice could affect staff in the kitchen.

Findings include:

During a tour of the facility with the Facility Manager on 11/13/19 at 3:13 p.m., 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 Facility 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 observation and interview, the facility failed to ensure 5 of over 500 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 in accordance with LSC 19.3.6.3. This deficient practice could affect patients, staff and visitors on the 7th, 6th, and 3rd floor.

Findings include:

During a facility tour with the Vice President Administrative Services, Director of Engineering and Maintenance, and Facility Manager, on 11/12/19 the following corridor doors were found to not latch when tested:
a) At 12:52 p.m. the door to 703.
b) At 1:13 p.m. the door to 624.
c) At 1:33 p.m. the door to 639.
d) At 2:34 p.m. the door to the pediatric play room.
Based on interview at the time of observations, the Vice President Administrative Services, Director of Engineering and Maintenance, and Facility Manager agreed that the above stated doors did not latch into the frame when tested.

Based on observation and interview, the facility failed to ensure 2 smoke barrier walls was maintained in accordance with LSC Section 19.3.7.5. Section 19.3.7.5 requires smoke barriers to be constructed in accordance with LSC Section 8.5 and shall have a minimum ½ hour fire resistive rating. Section 8.5.2 states that smoke barriers shall be continuous from outside wall to outside wall and continuous through all concealed spaces. This deficient practice could affect staff and patients on the 4th and 2nd floors.

Findings include:

During a facility tour with the Vice President Administrative Services, Director of Engineering and Maintenance, and Facility Manager, of the 4th floor on 11/12/19 an unsealed penetration was found around telecommunications cabling going through a 1.5 inch stubbed conduit in the smoke barrier at 2:16 p.m.. Then, at 3:00 p.m. while touring the 2nd floor, a 2 foot square section of drywall was missing from the smoke barrier above the lay-in ceiling above room 215. Both conditions were confirmed by the Facility Manager at the time of observation.

Based on observation and interview, the facility failed to ensure 1 set of smoke barrier doors would restrict the movement of smoke for at least 20 minutes. LSC 19.3.7.8 requires doors in smoke barriers shall comply with LSC Section 8.5.4. LSC 8.5.4.1 requires doors in smoke barrier shall close the opening leaving only the minimum clearance necessary for proper operation. This deficient practice could affect staff, visitors and patients on the first floor.

Findings include:

During a tour of the facility on 11/13/19 with the Facility Manager at 3:33 p.m. smoke door 1-9-14, near the Biomedical Engineering office, did not close when tested, leaving an approximate 3 foot opening. Upon inspection it was determined that the door hung up on the door closing device. Based on interview at the time of observation, the Facility Manager agreed the smoke door did not fully close when tested.

Based on observation and interview, the facility failed to ensure receptacles in 1 of over 7 bays did not have reversed polarity in accordance with NFPA 70. LSC 19.5.1.1 requires utilities comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition at 200.11 states no grounded conductor shall be attached to any terminal or lead so as to reverse the polarity. This deficient practice could affect one patient in Bay 7.

Findings include:

Based on observations with the Director of Engineering & Facilities and the Purchasing Manager for the Surgery Center during a tour of the facility from 8:30 a.m. to 10:20 a.m. on 11/14/19, the two receptacles in the wall mounted outlet box identified as "CR1-2" and the two electrical receptacles in the wall mounted outlet box identified as "NL3-SO" in Bay 7 were each found to have reversed polarity when tested with an Etcon UL listed circuit tester testing device. Based on interview at the time of the observations, the Director of Engineering & Facilities agreed the aforementioned receptacle locations had reversed polarity when tested with the Etcon device.

Based on record review and interview, the facility failed to document activation of the fire alarm system for fire drills conducted between 6:00 a.m. and 9:00 p.m. on the first shift for 4 of 4 quarters. LSC 21.7.1.4 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 in the facility.

Findings include:

Based on review of "Fire Drill Report" documentation with the Security Manager during record review from 10:00 a.m. to 2:50 p.m. on 11/13/19, documentation for four of four first shift fire drills conducted on 12/20/18, 03/22/19, 06/28/19 and 09/11/19 did not include activation of the fire alarm system and transmission of the fire alarm signal. Based on interview at the time of record review, the Security Manager stated the surgery center operates one shift per day, usually from 6:00 a.m. to 3:00 p.m., and fire drills are conducted to simulate fire drill training but the facility did not activate the fire alarm system and document the transmission of the fire alarm signal for each of the aforementioned four fire drills conducted after 6:00 a.m. but before 9:00 a.m.

Based on record review and interview, the facility failed to ensure 12 of 12 fire drills included the verification of transmission of the fire alarm signal to the monitoring station in fire drills for the last 4 quarters. LSC 19.7.1.4 requires fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. This deficient practice affects all patients in the facility as well as staff and visitors.

Findings include:

Based on record review of the document titled "Fire Drill Report" with the Manager of Engineering / Maintenance on 11/13/19 at 11:08 a.m., the documentation for the fire drills for the past twelve months lacked verification of the transmission of the alarm signal with the monitoring company. Based on interview at the time of record review, the Manager of Engineering / Maintenance stated that he did not know the verification of the transmission of the fire alarm signal for fire drills was necessary, and would now start to document the aforementioned verification of the transmission of the fire alarm signal with his monitoring company henceforth.

Based on observation and interview, the facility failed to ensure all circuits on the life safety branch supply power to circuits essential for life safety in accordance with NFPA 99. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 6.4.2.2.3.2 states the life safety branch shall supply power for lighting, receptacles, and equipment as follows:
(1) Illumination of means of egress in accordance with NFPA 101, Life Safety Code.
(2) Exit signs and exit directional signs in accordance with NFPA 101, Life Safety Code.
(3) Hospital communication systems, where used for issuing instruction during emergency conditions.
(4) Generator set location as follows:
(a) Task illumination
(b) Battery charger for emergency battery-powered lighting unit(s)
(c) Select receptacles at the generator set location and essential electrical system transfer switch locations
(5) Elevator cab lighting, control, communications, and signaling systems.
(6) Electrically powered doors used for building egress.
(7) Fire alarms and auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm and Signaling Code.
Section 6.4.2.2.3 states alarm and alerting systems (other than fire alarm systems) shall be connected to the life safety branch or the critical branch. Section 6.4.2.2.3.4 states loads dedicated to a specific generator, including the fuel transfer pump(s), ventilation fans, electrically operated louvers, controls, cooling systems, and other generator accessories essential for generator operation, shall be connected to the life safety branch or the output terminals of the generator with over-current protective devices. Section 6.4.2.2.3.5 states no functions other than those in 6.4.2.2.3.2, 6.4.2.2.3.3, and 6.4.2.2.3.4 shall be connected to the life safety branch, except as specifically permitted in 6.4.2.2.3. Section 6.4.2.2.6.1 states the life safety branch shall be kept independent of all other wiring and equipment. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on observations with the Director of Engineering & Facilities and the Purchasing Manager for the Surgery Center during a tour of the facility from 8:30 a.m. to 10:20 a.m. on 11/14/19, it could not be assured all life safety branch circuits were separated from non-life safety branch circuits. The facility has one diesel fired emergency generator rated at 400 kW and the facility has three transfer switches located in the main electrical room. The electrical panels in the main electrical room were connected to the emergency generator and to the normal source. The electrical panel identified as "EQ1" had equipment branch circuits contained within the panel and had a circuit identified as "Generator Feed". Based on interview at the time of the observations, the Director of Engineering & Facilities checked with Hospital staff who informed him the "Generator Feed" circuit is for the generator block heater and the battery charger for the generator and agreed this life safety branch circuit was not separated from non-life safety branch circuits.

Based on record review, observation and interview; the facility failed to ensure an annual fuel quality test was performed for the facility's diesel fuel fired generator. NFPA 99, Health Care Facilities Code, 2012 Edition Section 6.5.4.1.1.2 states Type 2 EES (Essential Electrical System) generator sets shall be inspected and tested in accordance with Section 6.4.4.1.1.3. Section 6.4.4.1.1.3 states maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, 2010 Edition, Chapter 8. NFPA 110, Section 8.3.8 states a fuel quality test shall be performed at least annually using tests approved by ASTM standards. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review with the Manager of Engineering Maintenance, Director of Engineering & Facilities and the Security Manager during record review from 10:00 a.m. to 2:50 p.m. on 11/13/19, documentation of an annual fuel quality test for the facility's diesel fuel fired emergency generator was not available for review. Based on interview at the time of record review, the Manager of Engineering Maintenance stated the facility has one diesel fired emergency generator and agreed documentation of an annual fuel quality test for diesel fuel within the most recent twelve month period was not available for review at the time of the survey. Based on observations with the Director of Engineering & Facilities and the Purchasing Manager for the Surgery Center during a tour of the facility from 8:30 a.m. to 10:20 a.m. on 11/14/19, the facility has one diesel fired emergency generator rated at 400 kW located outside the building.

Based on observation and interview, the facility failed to ensure 2 of 2 generators were in accordance with NFPA 99, 2012 Edition, Health Care Facilities Code Section 6.4.1.1.6.1. Section 6.4.1.1.6.1 states that Type 1 and Type 2 essential electrical system power sources shall be classified as Type 10, Class X, Level 1 generator sets per NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110 Section 7.3.1 states 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. NFPA 110 7.3.2 states the emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch. This deficient practice could affect staff and up to staff, visitors, and all patients.

Findings include:

During a facility tour with the Facility Manager on 11/14/19 at 9:42 a.m., it was found that Automatic Transfer Switch, Banks 6-11, which included Critical, Life Safety, and Equipment circuits, was not protected by battery powered emergency lighting. Based on interview at the time of observation, the Facility Manager agreed that the Automatic Transfer Switch was not protected by battery powered emergency lighting.

Based on observation and interview, the facility failed to ensure 1 of 1 extension cords including power strips were not used as a substitute for fixed wiring. LSC 21.5.1 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. LSC Section 4.5.7 states any building service equipment or safeguard provided for life safety shall be designed, installed and approved in accordance with all applicable NFPA standards. NFPA 99, Standard for Health Care Facilities, 2012 edition, defines patient care areas as any portion of a health care facility wherein patients are intended to be examined or treated. Patient care vicinity is defined as a space, within a location intended for the examination and treatment of patients, extending 6 ft (1.8 m) beyond the normal location of the bed, chair, table, treadmill, or other device that supports the patient during examination and treatment. A patient care vicinity extends vertically to 7 ft 6 in. (2.3 m) above the floor. NFPA 99, Section 10.4.2.3 states household or office appliances not commonly equipped with grounding conductors in their power cords shall be permitted provided they are not located within the patient care vicinity. This deficient practice could affect one patient and staff.

Findings include:

Based on observations with the Purchasing Manager for the Surgery Center during a tour of the facility from 8:30 a.m. to 10:20 a.m. on 11/14/19, a power strip for three Arthroscopy Pumps was laying in a storage area of the mobile cart for the pumps within the patient care vicinity in Operating Room 1. The power strip was identified as UL 1449. Based on interview at the time of the observations, the Purchasing Manager agreed a power strip was being used as a substitute for fixed wiring and in the patient care vicinity and was not the correct power strip for PCREE.

Based on observation and interview, the facility failed to ensure flexible cords were not used as a substitute for fixed wiring. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice affects staff only.

Findings include:

During a facility tour with the Vice President Administrative Services, Director of Engineering and Maintenance, and Facility Manager, from 11/12/19 to 11/14/19, the following conditions were found:
a) On 11/12/19 at 2:27 p.m., the 3rd floor nurse station break room had a refrigerator, microwave, and a toaster plugged into a surge protector.
b) On 11/13/19 at 11:09 a.m. the radiology informaticist office contained a refrigerator plugged into a surge protector.
c) On 11/13/19 at 11:36 a.m. the ultrasound staff lounge had a coffee pot and microwave plugged into a surge protector.
d) On 11/13/16 at 1:30 p.m. the OR medication room had a temperature alarm plugged into an extension cord. During interview, maintenance and the OR manager did not know when the extension cord was put into use, and could not advise if it was temporary.
e) On 11/13/19 at 3:42 p.m. the computer training room had an extension cord connected to a surge protector powering electronics.
f) On 11/13/19 at 4:08 p.m. the purchasing breakroom had a microwave plugged into a surge protector.
Based on interview at the time of each observation, the Facility Manager agreed that the surge protectors or extension cords were being used improperly. It was noted that all deficiencies listed above were corrected prior to the facility exit on 11/14/19.