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Based on observation and interview, the facility failed to ensure 1 of 25 patient room corridor doors would latch into the door frame or were provided with a device that exerts at least 5 pounds of pressure to keep the door tightly closed. This deficient practice could affect patients, staff and visitors on the second floor patient room smoke compartment.

Findings include:

Based on observation on 03/23/11 at 10:45 a.m. with the maintenance supervisor and safety coordinator, the corridor door to the second floor patient room 207 was equipped with a latch which would not latch into the door frame. The maintenance supervisor and safety coordinator stated at the time of the observation, they were not aware of the problem.

Based on observation and interview, the facility failed to ensure 1 of 1 storage room doors serving a hazardous area in the lab was self closing to prevent the passage of smoke. This deficient practice could affect staff in and near the hazardous area and lab.

Findings include:

Based on observation with the maintenance supervisor and safety coordinator on 03/22/11 at 2:40 p.m., the storage room door in the lab lacked a door closer. The room contained a large amount of combustibles which included lab supplies, reams of copy paper, copier ink and two gallons of white board wash. The maintenance supervisor and safety coordinator stated at the time of observation, they were not aware of the problem.

Based on observation and interview, the facility failed to ensure 3 of more than 20 smoke detectors were installed where air flow would not adversely affect its operation. NFPA 72, 2-3.5.1 requires detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could effect patients, staff and visitors in and near the areas where each of the smoke detectors are located.

Findings include:

Based on observations with the maintenance supervisor and safety coordinator on 03/23/11 between 10:00 a.m. and 11:20 a.m., the smoke detector in the therapy storage room, in the second floor break area and in the med-surge soiled utility room were located within two feet of an air supply duct. This was acknowledged by the maintenance supervisor and safety coordinator at the time of the observation.

Based on record review and interview, the facility failed to provide a complete written policy containing procedures to be followed to protect 25 of 25 patients in the event the automatic sprinkler system has to be placed out of service for 4 hours or more in a 24 hour period in accordance with LSC, Section 9.7.6.1. LSC, 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, Standard for Inspection, Testing and Maintenance of Water Based Fire Protection Systems. NFPA 25, 11-5(d) requires the local fire department to be notified of a sprinkler impairment and 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also to be notified. This deficient practice could affect all occupants in the facility including patients, staff and visitors.

Findings include:

Based on review of the facility's policy and procedure book with the maintenance supervisor and safety coordinator on 03/22/11 at 1:55 p.m., the fire watch procedure for an out of service automatic sprinkler system was incomplete. The procedure lacked the telephone number for the Indiana State Department of Health (317-233-5359) and the local fire department, and it did not include staff must be trained to perform fire watch rounds. The interview with the maintenance supervisor and safety coordinator at the time of the record review indicated no other policy or procedure was available to review.

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 to protect 25 of 25 patients in accordance with LSC, Section 9.6.1.8. LSC, 19.7.1.1 requires every health care occupancy to have in effect and available to all supervisory personnel a plan for the protection of all persons. All employees shall periodically be instructed and kept informed with respect to their duties under the plan. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 19.7.2.2 requires all fire safety plans to provide for the use of alarms, the transmission of the alarm to the fire department and response to alarms. 19.7.2.3 requires health care personnel to be instructed in the use of a code phrase to assure transmission of the alarm during a malfunction of the building fire alarm system. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of the facility's policy and procedure book with the maintenance supervisor and safety coordinator on 03/22/11 at 1:55 p.m., the fire watch procedure for an out of service automatic alarm system was not complete. The procedure lacked the required telephone numbers for the Indiana State Department of Health (317-233-5359) and the local fire department, and it did not include staff must be trained to perform fire watch rounds. The maintenance supervisor and safety coordinator stated at the time of record review, they had no other policy or procedure available to review.

Based on observation and interview, the facility failed to ensure 1 of 25 patient room corridor doors would latch into the door frame or were provided with a device that exerts at least 5 pounds of pressure to keep the door tightly closed. This deficient practice could affect patients, staff and visitors on the second floor patient room smoke compartment.

Findings include:

Based on observation on 03/23/11 at 10:45 a.m. with the maintenance supervisor and safety coordinator, the corridor door to the second floor patient room 207 was equipped with a latch which would not latch into the door frame. The maintenance supervisor and safety coordinator stated at the time of the observation, they were not aware of the problem.

Based on observation and interview, the facility failed to ensure 1 of 1 storage room doors serving a hazardous area in the lab was self closing to prevent the passage of smoke. This deficient practice could affect staff in and near the hazardous area and lab.

Findings include:

Based on observation with the maintenance supervisor and safety coordinator on 03/22/11 at 2:40 p.m., the storage room door in the lab lacked a door closer. The room contained a large amount of combustibles which included lab supplies, reams of copy paper, copier ink and two gallons of white board wash. The maintenance supervisor and safety coordinator stated at the time of observation, they were not aware of the problem.

Based on observation and interview, the facility failed to ensure 3 of more than 20 smoke detectors were installed where air flow would not adversely affect its operation. NFPA 72, 2-3.5.1 requires detectors shall not be located where air flow prevents operation of the detectors. This deficient practice could effect patients, staff and visitors in and near the areas where each of the smoke detectors are located.

Findings include:

Based on observations with the maintenance supervisor and safety coordinator on 03/23/11 between 10:00 a.m. and 11:20 a.m., the smoke detector in the therapy storage room, in the second floor break area and in the med-surge soiled utility room were located within two feet of an air supply duct. This was acknowledged by the maintenance supervisor and safety coordinator at the time of the observation.

Based on record review and interview, the facility failed to provide a complete written policy containing procedures to be followed to protect 25 of 25 patients in the event the automatic sprinkler system has to be placed out of service for 4 hours or more in a 24 hour period in accordance with LSC, Section 9.7.6.1. LSC, 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, Standard for Inspection, Testing and Maintenance of Water Based Fire Protection Systems. NFPA 25, 11-5(d) requires the local fire department to be notified of a sprinkler impairment and 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also to be notified. This deficient practice could affect all occupants in the facility including patients, staff and visitors.

Findings include:

Based on review of the facility's policy and procedure book with the maintenance supervisor and safety coordinator on 03/22/11 at 1:55 p.m., the fire watch procedure for an out of service automatic sprinkler system was incomplete. The procedure lacked the telephone number for the Indiana State Department of Health (317-233-5359) and the local fire department, and it did not include staff must be trained to perform fire watch rounds. The interview with the maintenance supervisor and safety coordinator at the time of the record review indicated no other policy or procedure was available to review.

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 to protect 25 of 25 patients in accordance with LSC, Section 9.6.1.8. LSC, 19.7.1.1 requires every health care occupancy to have in effect and available to all supervisory personnel a plan for the protection of all persons. All employees shall periodically be instructed and kept informed with respect to their duties under the plan. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 19.7.2.2 requires all fire safety plans to provide for the use of alarms, the transmission of the alarm to the fire department and response to alarms. 19.7.2.3 requires health care personnel to be instructed in the use of a code phrase to assure transmission of the alarm during a malfunction of the building fire alarm system. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of the facility's policy and procedure book with the maintenance supervisor and safety coordinator on 03/22/11 at 1:55 p.m., the fire watch procedure for an out of service automatic alarm system was not complete. The procedure lacked the required telephone numbers for the Indiana State Department of Health (317-233-5359) and the local fire department, and it did not include staff must be trained to perform fire watch rounds. The maintenance supervisor and safety coordinator stated at the time of record review, they had no other policy or procedure available to review.