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Based on document review and interview, the facility failed to maintain its grievance process and to ensure an address for lodging a grievance directly with the State agency was provided to the patient and/or the patient's representative for one facility.

Findings include:

1. Review of the policy/procedure Consumer Grievances (reviewed 1-20) and review of the Patient Rights and Responsibilities handbook (revised 10-19) lacked documentation indicating the address for submitting a grievance with the Indiana Protection and Advocacy Service (IPAS) agency.

3. On 1-21-21 at 1037 hours, the Quality Specialist A8 confirmed the above.

Based on record review, observation, and interview; the facility failed to ensure 15 of 15 fire dampers in the facility were inspected and provided necessary maintenance (see tag K522), failed to provide 1 of 1 written emergency fire safety plan that incorporated all items listed in NFPA 101, Section 19.7.2.2 (see tag K711), failed to ensure the hospital grade electrical receptacles in 16 of 16 patient sleeping rooms were tested at least annually (see tag K914) failed to maintain 1 of 1 Emergency Power Standby System in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Section 8.4.9, as required by NFPA 99 Health Care Facilities Code, Section 6.4.1.1.6.1 (see tag K918) and failed to ensure an annual fuel quality test was performed for 1 of 1 facility's diesel-powered 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 (see tag K918).

The cumulative effect of this systemic problem resulted in the facility's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

#1. Based on observation, record review and interview, the facility failed to ensure the hospital grade electrical receptacles in 16 of 16 patient sleeping rooms were tested at least annually. NFPA 99, Health Care Facilities Code 2012 Edition, Section 6.3.4.1.1 states where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. Additionally, Section 6.3.3.2, Receptacle Testing in Patient Care Rooms requires the physical integrity of each receptacle shall be confirmed by visual inspection. The continuity of the grounding circuit in each electrical receptacle shall be verified. Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed; and retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 grams (4 ounces). This deficient practice could affect all patients in the facility.
Findings include:

Based on observations during a tour of the facility with the Maintenance Coordinator and the Maintenance Forman on 01/21/21 between 11:00 a.m. and 1:00 p.m., the facility's 16 patient sleeping rooms contained four hospital grade electrical receptacles. Based on records review at 11:30 a.m., no documentation was available to show electrical receptacles in patient sleeping rooms were tested after initial installation, replacement, or servicing of the device. Based on interview at the time of the observation and records review, the Maintenance Forman confirmed all of the electrical receptacles in the patient sleeping rooms were hospital-grade and stated testing per NFPA 99, Receptacle Testing requirements has not been completed.

This finding was reviewed with the Maintenance Coordinator, the Maintenance Forman, and the Quality Improvement Assistant at the exit conference.

#2. Based on record review and interview, the facility failed to maintain 1 of 1 Emergency Power Standby System in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Section 8.4.9, as required by NFPA 99 Health Care Facilities Code, Section 6.4.1.1.6.1. NFPA 110 Section 8.4.9 states that all Level 1 Emergency Power Systems shall be tested at least once within every three years. Where the assigned class is greater than 4 hours, it shall be permitted to terminate the test after 4 hours. NFPA 99 Section 6.4.1.1.6.1 states that Type 1 and Type 2 essential electrical system power sources shall be classified at Type 10, Class X, Level 1 generator sets. This deficient practice could affect all patients in the facility.

Findings include:

During records review with the Maintenance Coordinator and the Maintenance Forman on 01/21/21 at 11:14 a.m., documentation of a four-hour continuous run under load for the emergency generator conducted within the last 36 months was not provided for review. Based on interview at the time of records review, the Maintenance Forman stated a four-hour continuous run under load was not conducted in the past 36 months.

#3. Based on record review and interview, the facility failed to ensure an annual fuel quality test was performed for 1 of 1 facility's diesel-powered 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 NFPA110, 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 in the facility.

Findings include:

During records review with the Maintenance Coordinator and the Maintenance Forman on 01/21/21 at 11:19 a.m., no documentation of an annual fuel quality test for the diesel generator was available for review. Based on interview at the time of records review, the Maintenance Forman stated the facility does have a diesel generator but was unaware of the fuel quality testing requirements and did not have the fuel tested.

The findings were reviewed with the Maintenance Coordinator, the Maintenance Forman, and the Quality Improvement Assistant at the exit conference.

Based on record review, observation, and interview; the facility failed to ensure 15 of 15 fire dampers in the facility were inspected and provided necessary maintenance. LSC 9.2.1 requires heating, ventilating and air conditioning (HVAC) ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 2012 Edition, Section 5.4.8.1 states fire dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80, 2010 Edition, Section 19.4.1 states each damper shall be tested and inspected 1 year after installation. Section 19.4.1.1 states the test and inspection frequency shall be every 4 years except for hospitals where the frequency is every 6 years. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The damper shall not be blocked from closure in any way. All inspections and testing shall be documented, indicating the location of the fire damper, date of inspection, name of inspector and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. This deficient practice could affect all patients in the facility.

Findings include:

Based on observation with the Maintenance Coordinator and the Maintenance Forman on 01/21/21 between 11:00 a.m. and 1:00 p.m., there were smoke/fire dampers noted in the HVAC duct work throughout the building. Based on records review at 10:30 a.m., no documentation of an inspection for the smoke/fire dampers in the facility was available for review. Based on interview at the time of records review and observation, the Maintenance Forman stated there are about 15 smoke/fire dampers in the facility and no inspection has been conducted since the dampers were installed over six years ago.

This finding was reviewed with the Maintenance Coordinator, the Maintenance Forman, and the Quality Improvement Assistant at the exit conference.

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 could affect all patients in the facility.

Findings include:

Based on records review with the Quality Improvement Assistant on 01/21/21 at 1:17 p.m., the provided facility's fire safety plan did not address the following items:
a) Extinguishment of fire. The fire safety plan did not indicate how use a fire extinguisher and did not address the types of fire extinguishers in the facility.
b) Evacuation of smoke compartment. The facility did not address how to evacuate a smoke compartment nor identify the smoke barrier walls and smoke compartments in the facility.
c) Emergency phone call to fire department. The facility did not address calling the fire department after activation of the fire alarm system or discovery of fire.
Based on interview at the time of records review, the Quality Improvement Assistant looked through the fire safety plan and stated the aforementioned items were not in the provided plan.

This finding was reviewed with the Maintenance Coordinator, the Maintenance Forman, and the Quality Improvement Assistant at the exit conference.