HospitalInspections.org

Based on observation and interview, the facility failed to provide a hard surface to a public way for 3 of 8 exit discharge areas. This deficient practice could affect all patients, as well as staff and visitors in the facility.

Findings include:

Based on observations on 12/18/18 between 1:15 p.m. and 2:30 p.m. during a tour of the facility with the Director of Environmental Care and Corporate Director of Environmental Care, the three west exits from the Willow Unit, Cedar Unit, and the middle exit to the smoking area all exited to a courtyard. There were no sidewalks to a public way from any of the three west exits. Based on interview at the time of observations, the Director of Environmental Care said the facility has already put in place a plan for adding sidewalks from all three west exits and was able to provide an overhead diagram of the facility with locations of the sidewalks to be constructed.

Based on record review and interview, the facility failed to provide a complete written policy for the protection of 45 of 45 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 occupants in the facility.

Findings include:

Based on record review on 12/18/18 between 10:00 a.m. and 1:15 p.m. with the Director of Environmental Care and Corporate Director of Environmental Care present, the facility provided fire watch documentation, however, it was incomplete. The plan failed to include the following:
a. The web link for contacting the Incident Reporting System located on the Indiana State Department of Health Gateway
b. The phone number for the local fire department
Based on an interview at the time of record review, the Director of Environmental Care agreed the fire watch policy lacked the previously mentioned information and said this was the only fire watch policy available.

Based on record review, observation and interview; the facility failed to document sprinkler system inspections in accordance with NFPA 25 for 1 of 1 sprinkler system. 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 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 in the facility.

Findings include:

Based on record review on 12/18/18 between 10:00 a.m. and 1:15 p.m. with the Director of Environmental Care and Corporate Director of Environmental Care present, there was documentation available that quarterly sprinkler inspections were performed on 01/25/18, 03/27/18, 06/11/18, and 09/14/18, plus one gauge and valve inspection in December of 2018 performed by in house staff. Monthly wet sprinkler system gauge inspection documentation for 7 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 7 months of the most recent 12 month period was also not available for review. Based on interview at the time of record review, the Director of Environmental Care said the facility performs regular visual sprinkler system inspections but has not documented sprinkler system gauge and system control valve inspections on a regular basis and acknowledged sprinkler system gauge and control valve inspection documentation for the aforementioned monthly periods was not available for review. Based on observations on 12/18/18 with the Director of Environmental Care and Corporate Director of Environmental Care during a tour of the facility from 1:15 p.m. to 2:30 p.m. there were two sprinkler system pressure gauges at the sprinkler riser.

Based on record review and interview, the facility failed to provide a complete written policy containing procedures to be followed for the protection of 45 of 45 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 9.7.6 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. A.15.5.2 (4) (b) states a fire watch should consist of trained personnel who continuously patrol the affected area. Ready access to fire extinguishers and the ability to promptly notify the fire department are important items to consider. During the patrol of the area, the person should not only be looking for fire, but making sure that the other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. This deficient practice could affect all occupants in the facility.

Findings include:

Based on record review on 12/18/18 between 10:00 a.m. and 1:15 p.m. with the Director of Environmental Care and Corporate Director of Environmental Care present, the facility provided fire watch documentation, however, it was incomplete. The plan failed to include the following:
a. The web link for contacting the Incident Reporting System located on the Indiana State Department of Health Gateway
b. The phone number for the local fire department
c. The phone number for the facility's insurance carrier
Based on an interview at the time of record review, the Director of Environmental Care agreed the fire watch policy lacked the previously mentioned information and said this was the only fire watch policy available.

Based on record review and interview, the facility failed to ensure documentation for 1 of 1 emergency generators included a 5 minute cool down period after a load test. 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, 6.4.2.1.5.9 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, as well as staff and visitors in the facility.

Findings include:

Based on record review on 12/18/18 between 10:00 a.m. and 1:15 p.m. with the Director of Environmental Care and Corporate Director of Environmental Care present, the monthly load test for the emergency generator had no information to show the generator had a cool down time following its load test. Based on interview at the time of record review, the Director of Environmental Care said the generator does have a cool down time after each monthly load test, but acknowledged it was not documented on the monthly generator load test form.