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Based on observation and interview, the facility failed to ensure 1 of 2 portable fire extinguishers in the Acute Rehabilitation Unity (ARU) Activity/Dining Room were not obstructed in accordance with NFPA 10. NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition, Chapter 6. Section 6.1.3.1 states that fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire; and Section 6.1.3.3.1 which states that fire extinguishers shall not be obstructed or obscured from view. This deficient practice could affect all occupants of the ARU Activity/Dining Room.

Findings include:

During a facility tour of the ARU with the Chief of Nursing Operations and Nursing Quality Manager on 04/22/2021 at 10:20 a.m. fire extinguisher #506 was obstructed from access and view by chair and two pieces of stored medical equipment. Based on interview at the time of observation, the Chief of Nursing Operations and Nursing Quality Manager agreed that the fire extinguisher was obstructed. It was noted that this condition was corrected prior to the exit.

This deficient finding was reviewed with the Chief of Nursing Operations at the time of exit.

Based on record review and interview, the facility failed to ensure that maintenance was completed in accordance with NFPA 101 4.6.12.5, which states that maintenance, inspection, and testing shall be performed under the supervision of a responsible person who shall ensure that testing, inspection, and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction. This deficient practice could impact all facility occupants.

Findings include:
1) Based on a record review and interview on 04/22/2021 between 10:30 a.m. and 12:00 p.m., with the Chief of Nursing Operations, Nursing Quality Manager, Quality Manager, and Director of Support Services present, the written "Detailed Master Equipment Report" indicated that the appliance involved in the fire was a Whirlpool Stackable Washer Dryer, Model Number WET3300XQ2. The Whirlpool Washer/Dryer Use and Care Guide for the appliance, states "Disconnect power before servicing" on page 16. Based on interview at the time of record review, the Director of Support Services stated that the appliance was plugged in, and was energized, when the appliance was being serviced at the time of the fire. He agreed that the appliance should have been disconnected from power before servicing.

2) Based on a record review and interview on 04/22/2021 between 10:30 a.m. and 12:00 p.m., with the Chief of Nursing Operations, Nursing Quality Manager, Quality Manager, and Director of Support Services present, the Safety Data Sheet for the lubricant used, Red Grease Lubricant, SDS #1000023427, states that the lubricant is an extremely flammable aerosol, and to be kept aware from heat, hot surfaces, sparks, open flames, and other ignition sources. Based on interview at the time of record review, the Director of Support Services stated that the lubricant used was not the proper lubricant as it was flammable.

This deficient practice was reviewed with the Chief of Nursing Operations at the time of exit.

This federal tag relates to Complaint Number IN00348453

Based on record review and interview, the facility failed to provide a written plan that addressed all components in 1 of 1 written fire plans. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire
In addition, LSC 19.3.4.2 states that healthcare occupancies shall be provided with a fire alarm system in accordance with Section 9.6. Section 9.6.4.2 states that the fire alarm system shall be arranged to transmit the alarm automatically.
This deficient practice could affect all occupants.

Findings include:

Based on a record review and interview on 04/22/2021 between 10:30 a.m. and 12:00 p.m., with the Chief of Nursing Operations, Nursing Quality Manager, Quality Manager, and Director of Support Services present, the written fire safety plan, titled "Code Red - Fire Safety" (adopted 08/05/2019) and the policy titled "Fire Alarm and Safety Guidelines" did not specifically address transmission of the fire alarm to the fire department (2) or a secondary emergency phone call to the fire department (3).

Based on interview with the Director of Support Services at the time of record review, the hospital had placed the fire alarm system on "by-pass" due to maintenance at the time of the incident. When the hospital fire alarm is on "by-pass", the off-site monitoring organization disregards alarms and the hospital Command Center is responsible for fire department notification.

Based on a record review and interview on 04/22/2021 between 10:30 a.m. and 12:00 p.m., with the Chief of Nursing Operations, Nursing Quality Manager, Quality Manager, and Director of Support Services present, the written "Fire Event Report" indicates that on 02/24/2021 at 12:40 p.m. the fire alarm was initiated by Waterflow alarm, Pull Station, and Smoke Detector. The Fire Response Team arrived at the incident location at 12:45 p.m. The Fire Event Report does not indicate that the East Chicago Fire Department was contacted automatically, or via a secondary emergency telephone call.

Based on interview with the Director of Support Services at the time of record review, he stated that after the conclusion of the fire, he contacted the East Chicago Fire Department and spoke to the Fire Inspector. After telling the Fire Inspector the fire was out, the Fire Inspector agreed that the Fire Department would not need to respond.

On 04/22/2021 at 12:30 p.m. the Fire Chief of the East Chicago Fire Department was interviewed. He stated that the department received no dispatch, or emergency communication from the hospital regarding the fire. The Fire Inspector was contacted non-emergency after the incident.

This deficient finding was reviewed with the Director of Support Services.

This federal tag relates to Complaint Number IN00348453