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Based on record review, observation and interview; the facility failed to maintain the 2-hour fire rated separation between the Hospital and the adjoining tenant in accordance with Section 19.1.3.4.1. This deficient practice could affect two staff and visitors in the main entrance lobby.

Findings include:

Based on review of facility blueprint information with the Chief Executive Officer (CEO), Vice President of Quality (VPQ), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during record review from 9:20 a.m. to 1:05 p.m. and from 2:45 p.m. to 4:15 p.m. on 12/28/17, a two hour fire rated wall separates the facility, Suite 100, from the adjoining tenant, a call center. A portion of the two hour tenant separation wall consists of the west wall of the main entrance lobby. Based on observations with the CEO, the CDPO and the DPO during a tour of the facility from 1:05 p.m. to 2:45 p.m. on 12/28/17, a three inch in diameter hole was noted in the west wall of the main entrance lobby above the suspended ceiling near a support truss for the roof deck above which did not maintain the two hour fire resistance rating of the tenant separation wall which consisted of four layers of five-eighths inch thick drywall. Based on interview at the time of the observations, the DPO agreed the aforementioned hole in the tenant separation wall did not maintain the two hour fire resistance rating of the wall.

Based on observation and interview, the facility failed to ensure 1 of 8 hazardous areas such as soiled linen rooms exceeding 64 gallons storage was separated from other spaces by smoke resistant partitions and doors. Doors shall be self closing or automatic closing in accordance with 7.2.1.8. This deficient practice could affect over 12 patients, staff and visitors in the vicinity of the soiled linen room by Room 1014.

Findings include:

Based on observations with the Chief Executive Officer (CEO), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during a tour of the facility from 1:05 p.m. to 2:45 p.m. on 12/28/17, the corridor door to the soiled linen room by Room 1014 was not equipped with a self closing device. The room contained soiled linen in three separate 32 gallon capacity trash bags in wheeled support carts. Based on interview at the time of the observations, the CDPO and DPO stated soiled linen is not normally stored in the room but agreed the door to the room was not equipped with a self closing device.

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 affects all patients, staff and visitors.

Findings include:

Based on review of "Interim Life Safety Measures" and "Fire Watch" documentation with the Chief Executive Officer (CEO), Vice President of Quality (VPQ), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during record review from 9:20 a.m. to 1:05 p.m. and from 2:45 p.m. to 4:15 p.m. on 12/28/17, the fire watch plan for fire alarm system impairment was incomplete. The plan stated to contact the Mental Health Division of the Indiana State Department of Health. The plan failed to include contacting the Indiana State Department of Health (ISDH) via the ISDH Gateway link at https://gateway.isdh.in.gov as the primary method or by the secondary method when the ISDH Gateway is nonoperational by completing the Incident Reporting form and e-mailing it to incidents@isdh.in.gov. Based on interview at the time of record review, the CDPO agreed the fire watch documentation for fire alarm system impairment stated to contact the Indiana State Department of Health but not via the ISDH Gateway link or at the e-mail address listed above.

1. Based on record review, observation and interview; the facility failed to ensure all private fire hydrants were continuously maintained in reliable operating condition and inspected and tested periodically. NFPA 25, 2011 Edition, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Table 7.1.1.2 requires wet and dry barrel hydrants to be inspected annually and after each operation. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on record review with the Chief Executive Officer (CEO), Vice President of Quality (VPQ), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during record review from 9:20 a.m. to 1:05 p.m. and from 2:45 p.m. to 4:15 p.m. on 12/28/17, documentation of fire hydrant inspection within the most recent twelve month period was not available for review. Based on observations with the DPO at 2:45 p.m. on 12/28/17, one red fire hydrant was noted in the facility parking lot by the emergency generator. Based on interview at the time of record review, the DPO stated he has worked at the facility for less than one year, did not know if the fire hydrant was maintained by the facility and stated documentation of fire hydrant inspection within the most recent twelve month period was not available for review.

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 USAutomatic Fire & Security's "Report of Inspection" documentation dated 03/06/17, 06/23/17, 09/20/17 and 12/18/17 with the Chief Executive Officer (CEO), Vice President of Quality (VPQ), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during record review from 9:20 a.m. to 1:05 p.m. and from 2:45 p.m. to 4:15 p.m. on 12/28/17, monthly wet sprinkler system gauge inspection documentation for 8 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 8 months of the most recent 12 month period was also not available for review. Based on interview at the time of record review, the CDPO and DPO stated the facility checks sprinkler gauges and valves but sprinkler system gauge and control valve inspection documentation for the aforementioned monthly periods was not available for review. Based on observations with the CEO, the CDPO and the DPO during a tour of the facility from 1:05 p.m. to 2:45 p.m. on 12/28/17, the facility has supervised wet sprinkler systems.

3. Based on record review, observation and interview; the facility failed to ensure the sprinkler system was maintained in accordance with NFPA 25. LSC 9.7.5 requires all sprinkler systems 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, Section 13.6.2.1 states all backflow preventers installed in fire protection system piping shall be tested annually by conducting a forward flow test of the system at the designed flow rate. Section 4.1.4.1 states the property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by this standard. 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 USAutomatic Fire & Security's "Backflow Prevention Assembly Test and Maintenance Report" documentation dated 08/24/17 with the Chief Executive Officer (CEO), Vice President of Quality (VPQ), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during record review from 9:20 a.m. to 1:05 p.m. and from 2:45 p.m. to 4:15 p.m. on 12/28/17, the Watts Model 975XL2 backflow prevention device was listed as "Failed" testing. No replace or repair documentation on or after 08/24/17 was available for review. Based on observations with the CEO, the CDPO and the DPO during a tour of the facility from 1:05 p.m. to 2:45 p.m. on 12/28/17, USAutomatic Fire & Security had affixed a hanging tag to the facility's wet sprinkler system riser documenting annual wet sprinkler system backflow prevention testing on 08/24/17 but it was also listed as "Fail." Based on interview at the time of the observations, the CDPO and DPO stated repair to the backflow preventer has not been performed yet because replacement parts are on order.

1. Based on record review, observation and interview; the facility failed to ensure all private fire hydrants were continuously maintained in reliable operating condition and inspected and tested periodically. NFPA 25, 2011 Edition, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, Table 7.1.1.2 requires wet and dry barrel hydrants to be inspected annually and after each operation. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on record review with the Chief Executive Officer (CEO), Vice President of Quality (VPQ), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during record review from 9:20 a.m. to 1:05 p.m. and from 2:45 p.m. to 4:15 p.m. on 12/28/17, documentation of fire hydrant inspection within the most recent twelve month period was not available for review. Based on observations with the DPO at 2:45 p.m. on 12/28/17, one red fire hydrant was noted in the facility parking lot by the emergency generator. Based on interview at the time of record review, the DPO stated he has worked at the facility for less than one year, did not know if the fire hydrant was maintained by the facility and stated documentation of fire hydrant inspection within the most recent twelve month period was not available for review.

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 USAutomatic Fire & Security's "Report of Inspection" documentation dated 03/06/17, 06/23/17, 09/20/17 and 12/18/17 with the Chief Executive Officer (CEO), Vice President of Quality (VPQ), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during record review from 9:20 a.m. to 1:05 p.m. and from 2:45 p.m. to 4:15 p.m. on 12/28/17, monthly wet sprinkler system gauge inspection documentation for 8 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 8 months of the most recent 12 month period was also not available for review. Based on interview at the time of record review, the CDPO and DPO stated the facility checks sprinkler gauges and valves but sprinkler system gauge and control valve inspection documentation for the aforementioned monthly periods was not available for review. Based on observations with the CEO, the CDPO and the DPO during a tour of the facility from 1:05 p.m. to 2:45 p.m. on 12/28/17, the facility has supervised wet sprinkler systems.

3. Based on record review, observation and interview; the facility failed to ensure the sprinkler system was maintained in accordance with NFPA 25. LSC 9.7.5 requires all sprinkler systems 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, Section 13.6.2.1 states all backflow preventers installed in fire protection system piping shall be tested annually by conducting a forward flow test of the system at the designed flow rate. Section 4.1.4.1 states the property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by this standard. 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 USAutomatic Fire & Security's "Backflow Prevention Assembly Test and Maintenance Report" documentation dated 08/24/17 with the Chief Executive Officer (CEO), Vice President of Quality (VPQ), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during record review from 9:20 a.m. to 1:05 p.m. and from 2:45 p.m. to 4:15 p.m. on 12/28/17, the Watts Model 975XL2 backflow prevention device was listed as "Failed" testing. No replace or repair documentation on or after 08/24/17 was available for review. Based on observations with the CEO, the CDPO and the DPO during a tour of the facility from 1:05 p.m. to 2:45 p.m. on 12/28/17, USAutomatic Fire & Security had affixed a hanging tag to the facility's wet sprinkler system riser documenting annual wet sprinkler system backflow prevention testing on 08/24/17 but was also listed as "Fail." Based on interview at the time of the observations, the CDPO and DPO stated repair to the backflow preventer has not been performed yet because replacement parts are on order.

Based on record review and interview, the facility failed to provide a complete written policy containing procedures to be followed for the protection of 47 of 47 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, 15.5.2 requires nine procedures that the impairment coordinator shall follow. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on review of "Interim Life Safety Measures" and "Fire Watch" documentation with the Chief Executive Officer (CEO), Vice President of Quality (VPQ), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during record review from 9:20 a.m. to 1:05 p.m. and from 2:45 p.m. to 4:15 p.m. on 12/28/17, the facility fire watch plan for automatic sprinkler system impairment was incomplete. The plan stated to contact the Mental Health Division of the Indiana State Department of Health. The plan failed to include contacting the Indiana State Department of Health (ISDH) via the ISDH Gateway link at https://gateway.isdh.in.gov as the primary method or by the secondary method when the ISDH Gateway is nonoperational by completing the Incident Reporting form and e-mailing it to incidents@isdh.in.gov. In addition, the written fire watch policy also did not include notification of the insurance carrier, the alarm monitoring company and the property owner or designated representative. Based on interview at the time of record review, the CDPO stated the fire watch documentation for automatic sprinkler system impairment stated to contact the Indiana State Department of Health but not via the ISDH Gateway link or at the e-mail address listed above and agreed the policy also did not include notification of the aforementioned three entities.

Based on observation and interview, the facility failed to ensure 3 of 26 corridor doors to patient sleeping rooms were provided with a means suitable for keeping the door closed, had no impediment to closing, latching and would resist the passage of smoke. This deficient practice could affect 16 patients, staff and visitors in the 100 Hall.

Findings include:

Based on observations with the Chief Executive Officer (CEO), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during a tour of the facility from 1:05 p.m. to 2:45 p.m. on 12/28/17, the corridor door to patient rooms 1006, 1007 and 1010 in the 100 Hall each did not have a latching mechanism which prevented each door from closing and latching into the door frame. Based on interview at the time of the observations, the CDPO and the DPO agreed the aforementioned corridor doors each had an impediment to closing and latching.

Based on observation and interview, the facility failed to ensure 3 of 3 sets of smoke barrier doors would restrict the movement of smoke for at least 20 minutes. LSC, Section 18.3.7.8(4) states rabbets, bevels, or astragals shall be required at the meeting edges of pairs or doors and doors in smoke barriers shall comply with LSC, Section 8.5.4. LSC, Section 8.5.4.1 requires doors in smoke barriers to close the opening leaving only the minimum clearance necessary for proper operation which is defined as 1/8 inch to restrict the movement of smoke. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of facility blueprint information with the Chief Executive Officer (CEO), Vice President of Quality (VPQ), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during record review from 9:20 a.m. to 1:05 p.m. and from 2:45 p.m. to 4:15 p.m. on 12/28/17, the facility suite measures 28,156 square feet in size. Based on interview at the time of record review, the VPQ stated the facility had two separate renovations in 2016 and 2017 to expand their suite size within the existing structure and had to construct or reconstruct a smoke barrier wall within the suite from outside wall to outside wall in order to have two separate smoke compartments within the suite. Based on observations with the Chief Executive Officer (CEO), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during a tour of the facility from 1:05 p.m. to 2:45 p.m. on 12/28/17, the set of corridor smoke barrier doors at the entrance to the 100 Hall near the main entrance for the facility had a one half inch gap in between the meeting edges of the door set and was not equipped with a rabbet, bevel, or astragal. The smoke barrier corridor door set at the exit of the 100 Hall into the 200 Hall was also not equipped with a rabbet, bevel, or astragal. In addition, the smoke barrier corridor door set at the exit of the 300 Hall into the administrative office area by the tenant separation wall was also not equipped with a rabbet, bevel, or astragal. Based on interview at the time of the observations, the CDPO and the DPO stated the aforementioned corridor smoke barrier door sets were not equipped with a rabbet, bevel, or astragal.

Based on observation and interview, the facility failed to ensure 3 of over 50 rooms was maintained in accordance with 18.7.5.6. 18.7.5.6 states combustible decorations shall be prohibited in any health care occupancy, unless one of the following criteria is met:
(1) They are flame-retardant or are treated with approved fire-retardant coating that is listed and labeled for application to the material to which it is applied.
(2) The decorations meet the requirements of NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.
(3) The decorations exhibit a heat release rate not exceeding 100 kW when tested in accordance with NFPA 289, Standard Method of Fire Test for Individual Fuel Packages, using the 20 kW ignition source.
(4)*The decorations, such as photographs, paintings, and other art, are attached directly to the walls, ceiling, and non-fire-rated doors in accordance with the following:
(a) Decorations on non-fire-rated doors do not interfere with the operation or any required latching of the door and do not exceed the area limitations of 18.7.5.6(b), (c), or (d).
(b) Decorations do not exceed 20 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is not protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.
(c) Decorations do not exceed 30 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is protected throughout by an approved supervised automatic sprinkler system in accordance with Section 9.7.
(d) Decorations do not exceed 50 percent of the wall, ceiling, and door areas inside patient sleeping rooms having a capacity not exceeding four persons, in a smoke compartment that is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
This deficient practice could affect over five staff and visitors.

Findings include:

Based on observations with the Chief Executive Officer (CEO), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during a tour of the facility from 1:05 p.m. to 2:45 p.m. on 12/28/17, the corridor door to Room 117, Room 127 and Room 174 each were covered 100 percent with holiday wrapping paper. Based on interview at the time of the observations, the CDPO stated the fire resistance rating of the wrapping paper was not available for review, the paper was not treated with fire retardant material and agreed the surface of each door was entirely covered with wrapping paper.

Based on record review, observation and interview; the facility failed to ensure 1 of 1 emergency generators was allowed a 5 minute cool down period after a load test for eleven months of the most recent twelve month period. Chapter 6.4.4.1.1.4(a) of 2012 NFPA 99 requires monthly testing of the generator serving the emergency electrical system to be in accordance with NFPA 110, the Standard for Emergency and Standby Powers Systems, Chapter 8. NFPA 110, 6.2.10 Time Delay on Engine Shutdown requires that a minimum time delay of 5 minutes shall be provided for unloaded running of the Emergency Power Supply (EPS) prior to shutdown. This delay provides additional engine cool down. This time delay shall not be required on small (15 kW or less) air-cooled prime movers. This deficient practice could affect all patients, staff and visitors in the facility.

Findings include:

Based on review of "Monthly Generator" documentation with the Chief Executive Officer (CEO), Vice President of Quality (VPQ), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during record review from 9:20 a.m. to 1:05 p.m. and from 2:45 p.m. to 4:15 p.m. on 12/28/17, emergency generator load testing documentation for monthly load tests for the eleven month period of January 2017 through November 2017 did not include the cool down time period for the load test. Based on interview at the time of record review, the CDPO stated the aforementioned documentation records the total time the generator operated during the test which is generally greater than 30 minutes and includes a cool down time period but acknowledged documentation of the cool down time period for each of the monthly load tests was not available for review. Based on observations with the DPO at 2:45 p.m. on 12/28/17, the diesel fired emergency generator for the facility is rated at 100 kW.

Based on observation and interview, the facility failed to ensure 1 of 1 cylinders of nonflammable gases such as oxygen were properly secured from falling in 1 of 1 200 Hall Med Rooms. NFPA 99, Health Care Facilities Code, 2012 Edition, Section 11.3.3 states storage for nonflammable gases with a total volume equal to or less than 300 cubic feet shall comply with the requirements in 11.3.3.1 and 11.3.3.2. Section 11.3.3.2 states precautions in handling cylinders specified in 11.3.3.1 shall be in accordance with 11.6.2. Section 11.6.2.3(11) states freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. This deficient practice could affect 10 patients, staff and visitors in the vicinity of the 200 Hall Med Room.

Findings include:

Based on observations with the Chief Executive Officer (CEO), the Corporate Director of Plant Operations (CDPO) and the Director of Plant Operations (DPO) during a tour of the facility from 1:05 p.m. to 2:45 p.m. on 12/28/17, one of one 'E' type oxygen cylinders in the 200 Hall Med Room was freestanding on the floor and was not properly chained or supported in a proper cylinder stand or cart. Based on interview at the time of the observations, the CDPO stated a nurse had probably left it in the room without a stand or cart and agreed the aforementioned 'E' type oxygen cylinder was not properly chained or supported in a proper cylinder stand or cart.