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Based on observation and interview, the facility failed to ensure the penetration in 3 of 4 fire barrier walls was maintained to ensure the fire resistance of the barrier. LSC 19.1.1.3 requires all health care facilities to be maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of the occupants. LSC 8.3.5.1 requires penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. The firestop system or device shall be tested in accordance with ASTM E 814, Standard Test Method for Fire Tests of Through Penetration Fire Stops, or ANSI/UL 1479, Standard for Fire Tests of Through-Penetration Fire Stops. This deficient practice could affect staff and up to 7 patients.

Findings include:

Based on an observation with the Director of Plant Engineering on 10/17/17 between 3:23 p.m. and 3:34 p.m., the following fire barriers had the following unsealed penetrations above the drop ceiling:
a) a three inch by eight inch piece of drywall was removed in the Ambulance fire barrier. Additionally, a half inch piece of drywall a removed and a quarter inch gap around the metal support beams.
b) a one inch gap in drywall and a quarter inch gap at the top of a pipe in the Orthopedic Storage fire barrier
c) a quarter inch gap inside conduit in the Administration fire barrier
Based on interview at the time of each observation, the Director of Plant Engineering acknowledged each aforementioned condition and provided the measurements.

Based on observation and interview, the facility failed to ensure 1 of 6 fire door sets were arranged to minimize air leakage. LSC, 7.2.4.3.9 requires all fire door assemblies in horizontal exit shall be designed and installed to minimize air leakage. This deficient could affect staff and up to 3 patients.

Findings include:

Based on observation with the Director of Plant Engineering on 10/17/17 at 1:15 p.m., the set of fire barrier cross-corridor doors by the Emergency Rooms had at least a ¼ inch gap along the center where the doors came together in the closed position. Based on interview at the time of observation, the Director of Plant Engineering confirmed the cross corridor doors were fire doors.

Based on observation and interview, the facility failed to ensure the lighting for 1 of 1 generator emergency lights was maintained. LSC 7.8.1.4 requires illumination shall be arranged so that that the failure of any single lighting unit does not result in an illumination level of less than 0.2 foot-candle in any designated area. This deficient practice could affect all occupants.

Findings include:

Based on observation with the Director of Plant Engineering on 10/17/17 at 11:41 a.m., one of the bulbs on the generator battery operated emergency was burnt out. Based on observation at the time of interview, the Director of Plant Engineering acknowledged the burnt out bulb.

Based on observation and interview, the facility failed to maintain protection of 1 of 2 stairways and 1 of 2 ceiling barriers in accordance of 19.3.1. LSC 19.3.1 requires protection of vertical opening 19.3.1. LSC 19.3.1 requires vertical opening shall be enclosed or protected in accordance with Section 8.6. LSC 8.6.1 requires every floor that separates stories in a building shall be constructed as a smoke barrier. LSC 19.3.1.1 requires where an enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Plant Engineering on 10/17/17 at 3:00 p.m. then again at 3:14 p.m., the Basement Mechanical room contained three ceiling penetrations inside conduit. Then again, one inch gap around the metal support beam in the West Stairwell above the drop ceiling near the North Door. Based on interview at the time of each observation, the Director of Plant Engineering acknowledged each penetration and provided the measurements.

Based on observation and interview, the facility failed to maintain protection of 1 of 1 Kitchen in accordance of 19.3.2. This deficient practice could affect staff and up to 2 patients in the radiology smoke compartment.

Findings include:

Based on observation with the Director of Plant Engineering on 10/17/17 at 1:04 p.m., the Kitchen contained fuel-fire equipment. The kitchen was open to the dining room. The dining room corridors failed to latch when tested. Based on interview at the time of observation, the Director of Plant Engineering acknowledged the hazardous area needs to be protected by, at least, either the kitchen or dining room.

Based on record review and interview, the facility failed to ensure the humidity in 1 of 4 anesthetizing locations were greater than 20 percent. NFPA 99 9.3.1.1 requires heating, cooling, ventilating, and process systems serving spaces or providing health care functions covered by this code or listed within ASHRAE 170, Ventilation of Health Care Facilities. ASHRAE 170, requires mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 20 percent or greater. This deficient practice could affect staff and up to 1 patient.

Findings include:

Based on record review with the Director of Plant Engineering on 10/17/17 at 4:08 p.m., one operating room was under 20 percent on 3/17/17 and 11/19/16. No other further documentation was available to show what response was performed. Based on interview at the time of record review, the Director of Plant Engineering acknowledged the aforementioned condition and confirmed no policy was in place to documented responses for when the humidity in anesthetizing locations drops below 20 percent.

Based on record review and interview, the facility failed to provide a complete 1 of 1 written policy for the protection of residents 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.

Findings include:

Based on record review with the Director of Plant Engineering on 10/17/17 at 3:58 p.m., the facility provided fire watch documentation but it was incomplete. The plan failed to include contacting the Indiana State Department of Health via the Web Portal and failed to include contacting the insurance company. Based on an interview record review, the Director of Plant Engineering acknowledged fire watch policy failed to include the web link for contacting the Incident Reporting System located on the Indiana State Department of Health (ISDH) Gateway.

Based on observation and interview, the facility failed to maintain 1 of 1 dry pipe hydraulic design information sign in accordance with 19.3.5.1. NFPA 13, 2010 Edition, Standard for the Installation of Sprinkler System, Section 24.5.1 requires that the installing contractor shall identify a hydraulically designed sprinkler system with a permanently marked weatherproof metal or rigid plastic sign secured with corrosion-resistant wire, chain, or other approved means. Such signs shall be placed at the alarm valve, dry pipe valve, preaction valve, or deluge valve supplying the corresponding hydraulically designed area. This deficient practice could affect staff and up to 2 patients.

Findings include:

Based on observation with the Director of Plant Engineering on 10/17/17 at 1:08 p.m., the MRI riser room did not contain a hydraulic design information sign on the standpipe. Based on interview at the time of observation, the Director of Plant Engineering confirmed that the new sprinkler pipe installed has not had a sign installed yet.

3.1-19(b)

1. Based on record review and interview, the facility failed to maintain 1 of 1 sprinkler system in accordance with LSC 9.7.5. LSC 9.7.5 requires all automatic sprinkler systems shall be inspected and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 2011 edition, Table 5.1.1.2 indicates the required frequency of inspection and testing. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Director of Plant Engineering on 10/17/17 at 10:42 a.m., two of the last twelve monthly control valve inspections, forty eight of the last fifty two weekly dry system gauge inspections, and eleven of the last twelve monthly wet system gauge inspections. Based on interview at the time of record review, the Director of Plant Engineering acknowledged the lack of documentation.

2. Based on observation and interview, the facility failed to maintain the ceiling construction in 1 of 1 Boiler room and 1 of 1 MRI rooms The ceiling tiles trap hot air and gases around the sprinkler and cause the sprinkler to operate at a specified temperature. NFPA 13, 2010 edition, 8.5.4.11 states the distance between the sprinkler deflector and the ceiling above shall be selected based on the type of sprinkler and the type of construction. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Plant Engineering on 10/17/17 at 11:58 a.m. then again at 1:09 p.m., the Boiler room dropped the sprinkler heads below a smoke partition. The smoke partition contained at least seventeen penetrations ranging from a quarter inch to two inches. Then again, the MRI equipment room contained a half inch to two inch gap around the MRI machine and the drop ceiling. Based on interview at the time of observation, the Director of Plant Engineering acknowledged the drop ceiling gaps.

3. Based on observation and interview, the facility failed to maintain the ceiling construction in 1 of 1 Kitchen in accordance with 19.3.5.3. LSC 19.3.5.3 states, where required by 19.1.6, buildings containing hospitals shall be protected throughout by an approved, supervised, automatic sprinkler system in accordance with Section 9.7. Section 9.7 indicates that automatic sprinkler system requires shall be in accordance with NFPA 13. NFPA 13, 2010 edition, Section 6.2.7 states plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic, or shall be listed for use around a sprinkler. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Plant Engineering on 10/17/17 at 1:00 p.m., the Kitchen had a missing escutcheon. Based on interview at the time of observation, the Director of Plant Engineering acknowledged the missing escutcheon.

Based on record review and interview, the facility failed to provide a 1 of 1 written policy containing procedures to be followed 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 could affect all occupants.

Findings include:

Based on record review with the Director of Plant Engineering on 10/17/17 at 3:58 p.m., the facility provided fire watch documentation but it was incomplete. The plan failed to include contacting the Indiana State Department of Health via the Web Portal and failed to include contacting the insurance company. Based on an interview record review, the Director of Plant Engineering acknowledged fire watch policy failed to include the web link for contacting the Incident Reporting System located on the Indiana State Department of Health (ISDH) Gateway.

Based on observation and interview, the facility failed to maintain protection of 1 of 1 Dining room corridor walls in accordance of 19.3.6.2. LSC 19.3.6.2, Construction of Corridor Walls, requires corridor walls shall form a barrier to limit the transfer of smoke. This deficient practice could affect staff and up to 2 patients in the radiology smoke compartment.

Findings include:

Based on observation with the Director of Plant Engineering on 10/17/17 at 1:05 p.m., the corridor wall behind the Dining room corridor doors contained a two inch by three inch piece of drywall removed. Based on interview at the time of observation, the Director of Plant Engineering acknowledged the aforementioned condition and provided the measurements.

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 2 of 3 smoke barrier walls were protected to maintain the smoke resistance of each smoke barrier. LSC Section 19.3.7.5 requires smoke barriers to be constructed in accordance with LSC Section 8.5 and shall have a minimum ½ hour fire resistive rating. This deficient practice could affect staff and all patients.

Findings include:

Based on observations with the Director of Plant Engineering on 10/17/17 at 3:38 p.m. then again at 3:40 p.m., a quarter inch gap inside conduit in the Oncology smoke barrier above the drop ceiling. Then again, a two inch gap around a wire in the Oncology Manager smoke barrier above the drop ceiling. Based on interview at the time of observation, the Director of Plant Engineering acknowledged each aforementioned conditions and provided the measurements.

Based on interview and observation, the facility failed to maintain testing of 1 of 1 elevator provided with firefighter recall in accordance with 9.4.6, Elevator Testing. LSC 9.4.6.2 states that all elevators with fire fighters' emergency operations in accordance with 9.4.3 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME A17.1/CSA B44, Safety Code for Elevators and Escalators. This deficient practice would affect staff only.

Findings include:

Based on observation with the Director of Plant Engineering on 10/17/17 at 10:45 a.m., there was an elevator equipped with elevator firefighter recall. Based on interview at the time of observation, the Director of Plant Engineering acknowledged the elevator was equipped with elevator firefighter recall; no monthly operation documentation was available for review.

Based on record review and interview, the facility failed to conduct quarterly fire drills at unexpected times for 3 of 4 quarters. This deficient practice affects all occupants.

Findings include:

Based on record review of the "Fire Drill Report" form with the Director of Plant Engineering on 10/17/17 between 9:30 a.m. and 11:30 a.m., three sequential third shift fire drills took place between 1:15 a.m. and 1:45 a.m. for three of the last four quarters. Based on interview at the time of record review, the Director of Plant Engineering acknowledged the fire drills lack of varying times within a shift.

Based on observation and interview, the facility failed to ensure 1 of 1 OR Manager's office and 1 of 1 Oncology Manager's office was maintained in accordance with 19.7.5.6. LSC 19.7.5.6 prohibits combustible decorations unless an exception was met. This deficient practice could affect staff only.

Findings include:

Based on observation with the Director of Plant Engineering on 10/17/17 at 1:25 p.m. then again at 2:03 p.m., OR Manager's office contained a candle with a wick. Then again, the Oncology Manager's office contained a candle with a wick. Based on interview at the time of each observation, the Director of Plant Engineering confirmed a wick was in each of the candles.

Based on observation and interview, the facility failed to ensure soiled linen/trash receptacles near 1 of 1 Equipment Center was maintained in accordance with 19.7.5.7. This deficient practice could affect staff and up to 5 patients.

Findings include:

Based on observation with the Director of Plant Engineering on 10/17/17 at 1:57 p.m., there were three containers of soiled linen in trash within a sixty four square foot area off of the corridor in the Equipment Center. The three containers added up to greater than thirty two gallons. Based on interview at the time of observation, the Director of Plant Engineering acknowledged the maximum gallons of soiled linen allowed open to the corridor per the square foot requirement was exceeded.

Based on observation, interview, and record review, the facility failed to enforce 1 of 1 policy for the use of portable space heaters in accordance with 19.7.8. This deficient practice could affect staff and up to 5 patients.

Findings include:

Based on observation with the Director of Plant Engineering on 10/17/17 at 1:28 p.m. then again at 2:08 p.m., a space heater was discovered in the OR Manager's office. Then again, a space heater was discovered in the Speech Therapy office. Based on interview and record review at the time of observation, the Director of Plant Engineering acknowledged the space heaters and confirmed that the facility's space heater policy does not allow space heaters in the facility.

Based on record review and interview, the facility failed to install gauge on 1 of 1 medical vacuum system. NFPA 99 2012 edition 5.1.8.2.3 states all pressure-sensing devices and mainline pressure gauges downstream of the source valves shall be provided with a gas-specific demand check fitting to facilitate service testing or replacement. This deficient practice could affect staff and all patients.

Findings include:

Based on record review with the Director of Plant Engineering on 10/17/17 between 9:30 a.m. and 11:30 a.m., the most recent medical vacuum inspection documentation by ARTEC Environment Monitoring indicated that "2nd Pressure Gauge Not On Gas Specific Demand Check Fitting." Based on interview at the time of observation, the Director of Plant Engineering acknowledged the aforementioned condition and confirmed no further documentation was available for review.

Based on record review and interview, the facility failed to protect 4 of 4 wet location Operating Rooms in accordance with 6.3.2.2.8. 2012 Health Care Facilities Code 99 6.3.2.2.2.8.4 states that operating rooms shall be considered to be a wet location unless a risk assessment conducted by the health care governing body determines otherwise. HCFC 6.3.2.2.8 requires wet procedure locations shall be provided with special protection against electrical shock. This deficient practice could affect staff and up to 4 patients.

Findings include:

Based on record review with the Director of Plant Engineering on 10/17/17 between 9:30 a.m. and 11:30 a.m., no risk assessment documentation was available for review. Based on interview at the time of record review, the Director of Plant Engineering confirmed no risk assessment had been performed and no electrical shock prevention was in place.

Based on record review and interview, the facility failed to ensure 1 of 1 emergency diesel powered generator was allowed a 5 minute cool down period after a load test. NFPA 110 8.4.5(4) requires a minimum time delay of 5 minutes shall be provided for unloaded running of the Emergency Power Supply (EPS) prior to shut down. This delay provides additional engine cool down. This deficient practice could affect all occupants.

Findings include:

Based on record review with the Director of Plant Engineering on 10/17/17 at 11:10 a.m., the generator log form documented the generator was tested monthly for at least 30 minutes under load, however, there was no documentation on the form that showed the generator had a cool down time following its load test. Based on interview at the time of record review, the Director of Plant Engineering acknowledged the lack of documentation.

1. Based on observation and interview, the facility failed to ensure 11 of 11 flexible cords were not used as a substitute for fixed wiring according to 9.1.2. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition, Article 400.8 requires that, unless specifically permitted, flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. This deficient practice affects staff and at least 5 patients.

Findings include:

Based on observation with the Director of Plant Engineering on 10/17/17 between 11:45 a.m. and 3:45 p.m., the following was discovered:
a) a surge protector was powering a dehumidifier in the Administration office
b) a surge protector was powering a refrigerator in the Radiology Staff room
c) an extension cord was powering a fan in the Therapy room
d) a surge protector was powering a refrigerator in the Laboratory
e) a surge protector was powering another surge protector powering a refrigerator and a dehumidifier in the Materials Storage room
f) a surge protector was powering a refrigerator in the ER Doctor's office
g) a surge protector was powering three other surge protectors powering television equipment in the Telephone Equipment room
Based on interview at the time of each observation, the Director of Plant Engineering acknowledged each improper surge protector and extension cord use.

2. Based on observation, record review, and interview, the facility failed to install 1 of 1 power strip according to 9.1.2. LSC 9.1.2 requires electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code. NFPA 70, 2011 Edition, Article 110.3(B) Installation and Use, states listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling. This deficient practice affects staff and up to 1 patient.

Findings include:

Based on observation with the Director of Plant Engineering on 10/17/17 at 1:43 p.m. then again at 2:16 p.m., a surge protector was powering an endoscopy scope medical unit in the Endoscopy room. Then again, a surge protector was powering three medical devices in the ER Nurse's station. Based on interview at the time of each observation, the Director of Plant Engineering was unable to provide UL 60601-1 documentation for the permanently installed power strips powering medical equipment.