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Based on observation and interview, the facility failed to ensure 2 of 2 sets of double corridor doors closed and latched automatically into the door frame. This deficient practice would not directly affect patients but could affect staff and visitors.

Findings includes:

Based on observations with the Director of Plant Operations on 08/05/14 from 2:30 p.m. to 3:45 p.m., the entrance to the Plant Operations/Information Services Area (Door # 410) and the entrance to the Administrative area were provided with a set of double corridor doors equipped with a slide bolt latch on one door which had to be manually latched to allow the other door to latch into the first door. The Director of Plant Operations at the time of observation acknowledged the doors would not automatically latch.

Based on observation and interview, the facility failed to ensure 1 of 1 corridors in the Obstetrics (OB) area was provided access to not less than two approved exits. LSC 18.2.5.9 requires every corridor shall provide access to not less than two approved exits in accordance with sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies. This deficient practice could affect any patient, staff or visitor in the OB area.

Findings include:

Based on observation with the Director of Plant Operations on 08/05/14 from 2:30 p.m. to 3:45 p.m., the fifty five foot long OB corridor was provided with one marked exit on one end of the corridor. On the opposite end of the corridor, there were two unmarked exit options. The first option was exiting with a staff access card through a magnetically locked door into an intervening nurses station before reaching the corridor. The second available option was exiting through a door leading directly to the corridor that was magnetically locked but could only be opened when the fire alarm was activated. Based on interview at the time of observation, the Director of Plant Operations acknowledged the OB corridor had only one approved, readily visible exit.

Based on observation and interview, the facility failed to ensure continuity of egress lighting for 1 of 6 emergency exits. LSC 7.8.1.3 requires the walking surface within the portions of the exit discharge to be illuminated to values of at least 1 foot candle of light. This deficient practice could affect patients on the west hall who could be evacuated through the west exit.

Finding include:

Based on observation with the Director of Plant Operations on 08/05/14 from 2:30 p.m. to 3:45 p.m., the exterior exit discharge path for the west exit was not equipped with light fixtures. The exterior exit discharge path extended at least 100 feet away from the building and continued to both the north and the south for at least 200 feet without illumination. Based on an interview at the time of observation, the Director of Plant Operations acknowledged the exit discharge path from the west exit lacked illumination.

Based on record review and interview, the facility failed to ensure 3 of 6 fire drills conducted between 6:00 a.m. and 9:00 p.m. for the last 4 quarters included the verification of transmission of the fire alarm signal to the monitoring station in fire the drill records. LSC 18.7.1.2 requires fire exit 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 review of Fire Drill Reports on 08/05/14 at 1:00 p.m. with the Director of Plant Operations, the documentation for the following drills performed between the hours of 6:00 a.m. and 9:00 p.m. for the past twelve months lacked verification of the transmission of the signal for drills: on 05/38/14 at 8:00 p.m., on 04/22/14 at 6:15 a.m., and on 01/31/14 at 8:00 a.m. Based on interview at the time of record review, the Director of Plant Operations acknowledged the transmission of the fire alarm signal for the aforementioned fire drills was not documented.

Based on record review and interview, the facility failed to ensure 1 of 1 diesel generators was exercised annually under supplemental load. NFPA 110, 1999 Edition, Standard for Emergency and Standby Power Systems, section 6-4.2.2 states diesel powered emergency power supply (EPS) installations that do not meet the requirements of section 6-4.2 shall be exercised monthly with the available emergency power supply system (EPSS) load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours. This deficient practice could affect all patients as well as staff and visitors.

Findings include:

Based on review the most recent load bank test which occurred on 04/25/13 and interview with the Director of Plant Operations on 08/05/14 at 2:00 p.m., the diesel powered generator does not achieve 30 percent of the nameplate rating when run under load and the facility has a load bank test conducted by an outside contractor on a yearly basis. Based on interview at the time of record review, the Director of Plant Operations acknowledged the most recent load bank test occurred more than twelve months ago.

Based on record review and interview, the facility failed to provide a written policy containing procedures to be followed 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 in order to protect 2 of 2 patients. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, 1998 Edition, the Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 1-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review and interview with the Director of Plant Operations on 08/05/14 at 2:15 p.m., the facility had a fire watch procedure for a sprinkler system failure but it did not address all components of LSC 9.7.6.1. Specifically, the plan did not include notification of the outage to the Indiana State Department of Health which is one of the authorities having jurisdiction.

Based on record review and interview, the facility failed to ensure its written fire watch policy addressed all procedures to be followed in this facility in the event the fire alarm system has to be placed out of service for 4 hours or more in a 24 hour period in accordance with LSC, Section 9.6.1.8 in order to protect 2 of 2 patients. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review and interview with the Director of Plant Operations on 08/05/14 at 2:15 p.m., the facility had a fire watch procedure for a fire alarm system failure, but it did not address all components of LSC Section 9.6.1.8. Specifically, the plan did not include notification of the outage to the Indiana State Department of Health which is one of the authorities having jurisdiction.

Based on observation and interview, the facility failed to ensure 2 of 2 sets of double corridor doors closed and latched automatically into the door frame. This deficient practice would not directly affect patients but could affect staff and visitors.

Findings includes:

Based on observations with the Director of Plant Operations on 08/05/14 from 2:30 p.m. to 3:45 p.m., the entrance to the Plant Operations/Information Services Area (Door # 410) and the entrance to the Administrative area were provided with a set of double corridor doors equipped with a slide bolt latch on one door which had to be manually latched to allow the other door to latch into the first door. The Director of Plant Operations at the time of observation acknowledged the doors would not automatically latch.

Based on observation and interview, the facility failed to ensure 1 of 1 corridors in the Obstetrics (OB) area was provided access to not less than two approved exits. LSC 18.2.5.9 requires every corridor shall provide access to not less than two approved exits in accordance with sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies. This deficient practice could affect any patient, staff or visitor in the OB area.

Findings include:

Based on observation with the Director of Plant Operations on 08/05/14 from 2:30 p.m. to 3:45 p.m., the fifty five foot long OB corridor was provided with one marked exit on one end of the corridor. On the opposite end of the corridor, there were two unmarked exit options. The first option was exiting with a staff access card through a magnetically locked door into an intervening nurses station before reaching the corridor. The second available option was exiting through a door leading directly to the corridor that was magnetically locked but could only be opened when the fire alarm was activated. Based on interview at the time of observation, the Director of Plant Operations acknowledged the OB corridor had only one approved, readily visible exit.

Based on observation and interview, the facility failed to ensure continuity of egress lighting for 1 of 6 emergency exits. LSC 7.8.1.3 requires the walking surface within the portions of the exit discharge to be illuminated to values of at least 1 foot candle of light. This deficient practice could affect patients on the west hall who could be evacuated through the west exit.

Finding include:

Based on observation with the Director of Plant Operations on 08/05/14 from 2:30 p.m. to 3:45 p.m., the exterior exit discharge path for the west exit was not equipped with light fixtures. The exterior exit discharge path extended at least 100 feet away from the building and continued to both the north and the south for at least 200 feet without illumination. Based on an interview at the time of observation, the Director of Plant Operations acknowledged the exit discharge path from the west exit lacked illumination.

Based on record review and interview, the facility failed to ensure 3 of 6 fire drills conducted between 6:00 a.m. and 9:00 p.m. for the last 4 quarters included the verification of transmission of the fire alarm signal to the monitoring station in fire the drill records. LSC 18.7.1.2 requires fire exit 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 review of Fire Drill Reports on 08/05/14 at 1:00 p.m. with the Director of Plant Operations, the documentation for the following drills performed between the hours of 6:00 a.m. and 9:00 p.m. for the past twelve months lacked verification of the transmission of the signal for drills: on 05/38/14 at 8:00 p.m., on 04/22/14 at 6:15 a.m., and on 01/31/14 at 8:00 a.m. Based on interview at the time of record review, the Director of Plant Operations acknowledged the transmission of the fire alarm signal for the aforementioned fire drills was not documented.

Based on record review and interview, the facility failed to ensure 1 of 1 diesel generators was exercised annually under supplemental load. NFPA 110, 1999 Edition, Standard for Emergency and Standby Power Systems, section 6-4.2.2 states diesel powered emergency power supply (EPS) installations that do not meet the requirements of section 6-4.2 shall be exercised monthly with the available emergency power supply system (EPSS) load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours. This deficient practice could affect all patients as well as staff and visitors.

Findings include:

Based on review the most recent load bank test which occurred on 04/25/13 and interview with the Director of Plant Operations on 08/05/14 at 2:00 p.m., the diesel powered generator does not achieve 30 percent of the nameplate rating when run under load and the facility has a load bank test conducted by an outside contractor on a yearly basis. Based on interview at the time of record review, the Director of Plant Operations acknowledged the most recent load bank test occurred more than twelve months ago.

Based on record review and interview, the facility failed to provide a written policy containing procedures to be followed 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 in order to protect 2 of 2 patients. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, 1998 Edition, the Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 1-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review and interview with the Director of Plant Operations on 08/05/14 at 2:15 p.m., the facility had a fire watch procedure for a sprinkler system failure but it did not address all components of LSC 9.7.6.1. Specifically, the plan did not include notification of the outage to the Indiana State Department of Health which is one of the authorities having jurisdiction.

Based on record review and interview, the facility failed to ensure its written fire watch policy addressed all procedures to be followed in this facility in the event the fire alarm system has to be placed out of service for 4 hours or more in a 24 hour period in accordance with LSC, Section 9.6.1.8 in order to protect 2 of 2 patients. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review and interview with the Director of Plant Operations on 08/05/14 at 2:15 p.m., the facility had a fire watch procedure for a fire alarm system failure, but it did not address all components of LSC Section 9.6.1.8. Specifically, the plan did not include notification of the outage to the Indiana State Department of Health which is one of the authorities having jurisdiction.