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A Validation Survey was conducted by the Indiana State Department of Health.

Survey Date(s): 07/16/18 to 07/18/18

Facility Number: 006106

Kindred Hospital Indianapolis was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR 482.41(b), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies.

This one story facility was determined to be of Type II (000) construction and was fully sprinklered. The facility has a fire alarm system with hard wired smoke detectors in the corridors, spaces open to the corridors, and patient sleeping rooms. The facility has a capacity of 59 and had a census of 24 at the time of this survey.

All areas where the patients have customary access were sprinklered and all areas providing facility services were sprinklered.

Based on record review, observation and interview, the facility failed to ensure the corridor door to 1 of over 5 hazardous areas, such as a room used for storage of combustible items and was over 50 square feet, was provided with a self-closing device which would cause the door to automatically close and latch into the door frame (see tag K321), the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with 9.6.1.3. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code (see tag K345), the facility failed to ensure egress corridors were not used as a portion of a return air system serving adjoining rooms for 1 of 1 Wound care offices (see tag K521), the facility failed to ensure 4 of 9 ground fault interrupters (GFI) tested were functioning properly (see tag K912), the facility failed to ensure 1 of 4 surge protectors observed were not used as a substitute for fixed wiring (see tag K920).

The cumulative effect of these systemic problems resulted in the hospitals inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on observation and interview, the facility failed to ensure the corridor door to 1 of over 5 hazardous areas, such as a room used for storage of combustible items and was over 50 square feet, was provided with a self-closing device which would cause the door to automatically close and latch into the door frame. This deficient practice could affect visitors and staff on east hall, the facility failed to ensure 1 of 1 fire alarm systems was maintained in accordance with 9.6.1.3. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm Code. NFPA 72, 2010 Edition, Section 14.4.5 requires testing shall be performed in accordance with Table 14.4.5 Testing Frequencies. NFPA 72, Table 14.4.5 at 15(a) and 15(h) states duct detector initiating devices shall be functional tested annually. Section 14.6.2.4 states a record of all inspections, testing and maintenance shall be provided that includes all applicable information requested in Figure 14.6.2.4. This deficient practice could affect all patients, staff and visitors, the facility failed to ensure egress corridors were not used as a portion of a return air system serving adjoining rooms for 1 of 1 Wound care offices. LSC 9.2.1 requires air conditioning, heating, ventilating ductwork and related equipment to be installed in accordance with NFPA 90A, the Standard for the Installation of Air Conditioning and Ventilating Systems. NFPA 90A, Section 4.3.12.1.1 states egress corridors in nursing and long term care facilities shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas unless otherwise permitted by 4.3.12.1.3.1 through 4.3.12.1.3.4. This deficient practice could affect only staff and visitors.

Findings include:

1. Based on observation on 07/16/18 at 1:40 p.m. with the Director of Plant Operations, the storage room on east hall had 18 cardboard boxes and measured 128 square feet and did not have a closing device on the door to automatically allow the door to close and latch into its frame. Based on interview with the Director of Plant Operations concurrent with the observation it was acknowledged the door to the storage room was determined to be a hazardous area and the door was not equipped with a closing device.

2. Based on review of Tyco SimplexGrinnell 's "Duct Detector Devices Results Summary" and "Inspection Summary" documentation dated 05/09/18 with the Regional Facilities Director and the Director of Plant Operations during record review from 9:45 a.m. to 3:30 p.m. on 07/16/18, 21 of 76 duct detectors were listed as "Failed" annual functional testing. Additional duct detector functional testing documentation within the most recent twelve month period was not available for review and repair or replacement documentation of the 21 duct detectors on or after 07/16/18 was also not available for review. Based on interview at the time of record review, the Director of Plant Operations stated the facility switched fire alarm system contractors within the last year and the new contractor did not feel it was safe to test the 21 duct detectors due to height or inaccessibility even though the former contractor tested the detectors as evidenced by Esco Communications "Sensitivity Testing" documentation dated 05/25/17. Esco Communications submitted a quote to retest the 21 duct detectors as evidenced by "Annual Fire Alarm Inspection (Duct Detectors Only)" and "Purchase Order" documentation dated 06/05/18 but the date for retesting could not be confirmed other than the estimated date of 07/30/18 as stated in Esco's e-mail to the facility on 07/09/18. Based on interview at the time of the exit interview at 11:45 a.m. on 07/17/18, the Regional Facilities Director and the Director of Plant Operations agreed duct detector functional testing on or after 05/09/18 had not yet been performed.

3. Based on observation on 07/16/18 during a tour of the facility from 1:10 p.m. to 3:00 p.m. with the Director of Plant Operations the Wound care office had a supply air duct in the room, but was using the egress corridor as a return air system. Based on interview at the time of the observation, the Director of Plant Operations acknowledged the Wound care office did not have a return in the room, but rather used to corridor as a return air plenum.

Based on observation, testing and interview the facility failed to ensure 4 of 9 ground fault interrupters (GFI) tested were functioning properly. This deficient practice could affect only staff or visitors in the Education room or Radiology, the facility failed to ensure 1 of 4 surge protectors observed were not used as a substitute for fixed wiring. LSC 19.5.1 requires utilities to comply with Section 9.1. LSC 9.1.2 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 2011 Edition. NFPA 70, 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. LSC Section 4.5.7 states any building service equipment or safeguard provided for life safety shall be designed, installed and approved in accordance with all applicable NFPA standards This deficient practice could affect only staff and visitors.

Findings include:

1. Based on observations and testing on 07/16/18 during the tour between 1:00 p.m. to 3:00 p.m. with the Director of Plant Operations the GFI located in the Education room when tested and tripped could not be reset. In addition, three GFI's located in the darkroom of Radiology had three GFI's which simply had no power supply and would not work. The Director of Plant Operations tried to research potential reasons for this anomaly, but without result. Based on interview concurrent with the observations with the Director of Plant Operations it was acknowledged the aforementioned GFI's were defective and needed to be replaced.

2. Based on observation on 07/16/18 during the tour between 1:20 p.m. to 3:30 p.m. with the Director of Plant Operations a microwave was plugged into a surge protector in the Maintenance room. In addition, the Case Management office a two surge protectors piggybacked to each other used for various electrical appliances. Based on interview at the time of observations with the Director of Plant Operations it was verified and acknowledged a surge protector was used to power a microwave and two surge protectors were used in tandem and both instances were not allowed in the facility.