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Based on Life Safety Code (LSC) survey, St. Catherine Hospital Inc. was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety From Fire and the 2000 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies.

This seven story facility with a basement was determined to be of Type II (222) construction and was partially sprinklered. The hospital consists of four connected buildings: The patient Tower, the Block building, the "E" building and the Physician's office building. (POB)
The facility has a fire alarm system with smoke detection in the corridors and spaces open to the corridors. The facility has a capacity of 168 beds and had a census of 103 at the time of this survey.

St. Catherine Hospital has elected to utilize the categorical Life Safety Code waiver pertaining to relative humidity.

Based on LSC survey and deficiencies found (see CMS 2567L), it was determined that the facility failed to ensure elevator shafts were enclosed with construction with a fire resistance rating of at least one hour in 2 of 4 buildings (see K 020), failed to ensure the travel distance from the most remote point to a smoke barrier does not exceed 200 feet in 2 of 4 buildings (see K 024), failed to ensure at least two exits with a least one exit providing a continuous path of travel to an exit discharge were provided in 2 of 4 buildings (see K 032), failed to ensure the travel distance to an exit does not exceed 150 feet in 2 of 4 buildings (see K 036), failed to ensure the width of aisles or corridors serving as exit access was at least four feet in 2 of 4 buildings (see K 039), failed to provide exterior emergency lighting for 28 of 31 exits (see K 046), failed to ensure sprinklers in areas where cubicle curtains were provided in 25 of 25 patient rooms on the 5th floor Acute Rehab Unit (see K 056), failed to electronically supervise 2 of 10 sprinkler valves in the Physician's Office Building (POB) (see K 061), failed to ensure 3 of 3 fire pumps were provided with an adequate and reliable water supply for the automatic sprinkler system (see K 063), failed to ensure all sources of fuel and electric power that produce heat to all equipment requiring protection by that system shall automatically shut off for 2 of 2 kitchen fire extinguishing systems and failed to install and maintain 2 of 2 kitchen hood exhaust systems (see K 069), failed to enforce it's space heater policy in employee areas for the use of 1 of 1 portable space heaters in the facility (see K 070), failed to ensure 2 of 2 emergency generators were provided with an alarm annunciator in a location readily observed by operating personnel at a regular work station such as a nurse station and failed to ensure 2 of 2 emergency generators with over 100 horsepower were equipped with a remote manual stop (see K144), failed to ensure ground fault circuit interrupter (GFCI) receptacles on 4 of 7 floors were provided and operated properly to protection against electric shock and failed to ensure high current draw electrical devices were not plugged into powerstrips or fused multiplug adapters as a substitute for fixed wiring on 1 of 7 floors (see K 147), failed to provide a complete written policy indicating 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 (see K 154), 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 (see K 155) and failed to ensure 10 of 10 alcohol based hand rub dispensers within the Intensive Care Unit (ICU) were not installed over an ignition source (see K 211).

The cumulative effect of these systemic problems resulted in the hospital's 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 record review, observation and interview, the facility failed to ensure elevator shafts were enclosed with construction with a fire resistance rating of at least one hour in 2 of 4 buildings, failed to ensure the travel distance from the most remote point to a smoke barrier does not exceed 200 feet in 2 of 4 buildings, failed to ensure at least two exits with a least one exit providing a continuous path of travel to an exit discharge were provided in 2 of 4 buildings, failed to ensure the travel distance to an exit does not exceed 150 feet in 2 of 4 buildings, failed to ensure the width of aisles or corridors serving as exit access was at least four feet in 2 of 4 buildings (see K 039), failed to provide exterior emergency lighting for 28 of 31 exits, failed to ensure sprinklers in areas where cubicle curtains were provided in 25 of 25 patient rooms on the 5th floor Acute Rehab Unit, failed to electronically supervise 2 of 10 sprinkler valves in the Physician's Office Building (POB), failed to ensure 3 of 3 fire pumps were provided with an adequate and reliable water supply for the automatic sprinkler system, failed to ensure all sources of fuel and electric power that produce heat to all equipment requiring protection by that system shall automatically shut off for 2 of 2 kitchen fire extinguishing systems and failed to install and maintain 2 of 2 kitchen hood exhaust systems, failed to enforce it's space heater policy in employee areas for the use of 1 of 1 portable space heaters in the facility, failed to ensure 2 of 2 emergency generators were provided with an alarm annunciator in a location readily observed by operating personnel at a regular work station such as a nurse station and failed to ensure 2 of 2 emergency generators with over 100 horsepower were equipped with a remote manual stop, failed to ensure ground fault circuit interrupter (GFCI) receptacles on 4 of 7 floors were provided and operated properly to protection against electric shock and failed to ensure high current draw electrical devices were not plugged into powerstrips or fused multiplug adapters as a substitute for fixed wiring on 1 of 7 floors, failed to provide a complete written policy indicating 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, 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 and failed to ensure 10 of 10 alcohol based hand rub dispensers within the Intensive Care Unit (ICU) were not installed over an ignition source.

Findings:

1. Review of a Fire Safety Evaluation System (FSES) Fire Safety Features Record Drawings dated 02/22/2013 with RDE1, VPE1 and DE1 on 03/05/14 from 9:30 a.m. to 2:30 p.m. indicated the public and staff elevators in the "E" building and Block wing were equipped with standard steel doors that do not bear a label indicating the fire resistive rating.

2. In interview at the time of record review, DE1 acknowledged the facility utilizes the FSES to demonstrate an equivalent level of safety to NFPA 101, the Life Safety Code for the aforementioned condition.

3. Review of a Fire Safety Evaluation System (FSES) Fire Safety Features Record Drawings dated 02/22/2013 with RDE1, VPE1 and DE1 on 03/05/14 from 9:30 a.m. to 2:30 p.m. indicated the travel distance from the most remote point to a smoke barrier exceed 200 feet in Zones 2B, 4A, 5A and 1J.

4. In interview at the time of record review, DE1 acknowledged the facility utilizes the FSES to demonstrate an equivalent level of safety to NFPA 101, the Life Safety Code for the aforementioned condition.

5. Review of a Fire Safety Evaluation System (FSES) Fire Safety Features Record Drawings dated 02/22/2013 with RDE1, VPE1 and DE1 on 03/05/14 from 9:30 a.m. to 2:30 p.m. indicated exit stairs in the "E" building and Block wing do not discharge to the outside or through an approved exit passageway.

6. In interview at the time of record review, DE1 acknowledged the facility utilizes the FSES to demonstrate an equivalent level of safety to NFPA 101, the Life Safety Code for the aforementioned condition.

7. Review of a Fire Safety Evaluation System (FSES) Fire Safety Features Record Drawings dated 02/22/2013 with RDE1, VPE1 and DE1 on 03/05/14 from 9:30 a.m. to 2:30 p.m. indicated the travel distance to an exit exceeds 150 feet in Zones 1B and 1J.

8. In interview at the time of review, DE1 acknowledged the facility utilizes the FSES to demonstrate an equivalent level of safety to NFPA 101, the Life Safety Code for the aforementioned condition.

9. Review of a Fire Safety Evaluation System (FSES) Fire Safety Features Record Drawings dated 02/22/2013 with RDE1, VPE1 and DE1 on 03/05/14 from 9:30 a.m. to 2:30 p.m. indicated the corridor width was reduced to less than four feet in Zones 1F and 1J.

10. In interview at the time of record review, the Director of Engineering acknowledged the facility utilizes the FSES to demonstrate an equivalent level of safety to NFPA 101, the Life Safety Code for the aforementioned condition.

11. Observation with RDE1, VPE1 and DE1 during a tour of the facility on 03/06/14 from 8:15 a.m. to 12:00 p.m. indicated battery operated lights were not being used for the exterior lighting.

12. In interview on 03/06/14 at 3:00 p.m., DE1 acknowledged the outpatient exit from the Physician's office building, the "E" building dietary and the Emergency Department exit were the only exits with exterior lighting connected to the generator and exterior emergency lighting would be provided for all exits when the two new generators are installed in several months.

13. Observation with RDE1, VPE1 and DE1 during a tour of the facility on 03/06/14 from 8:15 a.m. to 12:00 p.m. indicated the shower in the private bathrooms serving patient rooms 581, 589 and 588 were provided with a vinyl shower curtain with no top panel of at least a 1/2 inch diagonal mesh or a 70 percent open weave top panel extending 18 inches below the sprinkler deflector.

14. In interview at the time of the exit conference, DE1 confirmed there were 25 patient rooms on the 5th floor Acute Rehab Unit with private bathroom shower curtains with no mesh top panel.

15. Observation with DE1 on 03/06/14 from 1:00 p.m. to 2:00 p.m. indicated electronic supervision was not provided on two of the ten OS&Y valves on the POB building sprinkler system where the riser came into the building.

16. In interview at the time of observation, DE1 acknowledged the two sprinkler OS & Y valves lacked electronic supervision.

17. Observation with DE1 on 03/06/14 from 1:00 p.m. to 2:00 p.m. indicated electronic supervision was not provided on two of the ten OS&Y valves on the POB building sprinkler system where the riser came into the building.

18. In interview at the time of observation, DE1 acknowledged the two sprinkler OS & Y valves lacked electronic supervision.

19. Review of the range hood suppression system inspection reports dated 01/17/14 and 07/16/13 on 03/05/14 during record review from 9:30 a.m. to 2:30 p.m. with EQC1 indicated the reports had no verification of natural gas and/or electrical shut off testing for the two inspections.

20. In interview from 8:15 a.m. to 12:00 p.m. on 03/06/14 with DE1 indicated a natural gas and /or electrical shutoff for the main cooking area and serving line cooking area fire suppression systems could not be verified.

21. Observation on 03/06/14 from 8:15 a.m. to 12:00 p.m. with RDE1, VPE1 and DE1 indicated the main cooking area kitchen hood exhaust system and the serving line kitchen hood exhaust system had metal tags affixed to them stating, "Cleaning Instructions: Press trip arm, open panels, wipe grease each day from panels, baffles and gutter."

22. In interview at the time of of observation, the DFN1 indicated the hood exhaust system lacked filters and acknowledged it was not known why there were no filters provided in the commercial kitchen exhaust hoods.

23. Observation with DE1 during a tour of the facility on 03/05/14 from 2:30 p.m. to 4:30 p.m. indicated a space heater plugged into a power source and operating in the third floor West Clinical Case Manager's office.

24. In interview at the time of observation, DE1 acknowledged the facility was not aware of that particular space heater and acknowledged the space heater had not been checked to ensure the heating element does not exceed 212 degrees Fahrenheit.

25. Observation on 03/06/14 from 8:15 a.m. to 12:00 p.m. with DE1 indicated remote alarm annunciators for the two generators were not provided in a location readily observed by operating personnel at a regular work station.

26. In interview at the time of observation, DE1 acknowledged the lack of generator remote annunciators at a regular work station.

27. Observation on 03/06/14 from 8:15 a.m. to 12:00 p.m. with DE1 indicated one of the two generators in the generator room was equipped with a remote manual stop switch at the generator location but not at a remote location. The other generator in the generator room was not equipped with a remote manual stop switch at the generator location or at a remote location.

28. In an interview at the time of observation, DE1 acknowledged each of the generator engines provide more than 100 horsepower and lack remote manual stop stations.

29. Observations with RDE1, VPE1 and DE1 during a tour of the facility on 03/05/14 from 2:30 p.m. to 4:30 p.m. and on 03/06/14 from 8:15 a.m. to 12:00 p.m. indicated there were electrical receptacles within three feet of a sink that were not provided with GFCI protection at the 6th floor West nourishment station, 6th floor West soiled utility room, 5th floor West nourishment station, 5th floor West soiled utility room, 3rd floor West nourishment station, 3rd floor West locker room, 4th floor "E" sleep lab, soiled utility room and the 4th floor "E" nutrition.

30. In interview at the times of observation, RDE1, VPE1 and DE1 acknowledged the aforementioned wet location areas were not provided with GFCI protection.

31. Observation with DE1during a tour of the facility on 03/05/14 from 2:30 p.m. to 4:30 p.m. indicated a microwave, toaster oven and a toaster were plugged into power strip in the 5th floor West employee locker room.

32. In interview at the times of observation, DE1 acknowledged the aforementioned condition.

33. Review of the facility's fire watch policy and procedure on 03/05/14 during record review from 9:30 a.m. to 2:30 p.m. with the Engineering Quality Coordinator indicated the fire watch procedure for an out of service sprinkler system was not complete. The policy and procedure did not include notification to the Indiana State Department of Health, which is an authority having jurisdiction.

34. In interview at the time of record review, EQC1 acknowledged the fire watch policy and procedure did not include notification to the Indiana State Department of Health.

35. Review of the facility's fire watch policy and procedure on 03/05/14 during record review from 9:30 a.m. to 2:30 p.m. with EQC1 indicated the fire watch procedure for an out of service fire alarm system was not complete. The policy and procedure did not include notification to the Indiana State Department of Health, which is an authority having jurisdiction.

36. In interview at the time of record review, EQC1 acknowledged the fire watch policy and procedure did not include notification to the Indiana State Department of Health.

37. Observation on 03/05/14 with VPE1 during the tour from 2:30 p.m. to 4:30 p.m. indicated the ten ICU rooms had an alcohol based hand rub dispenser mounted on the corridor wall directly above an electrical outlet.

38. In interview with VPE1, it was acknowledge the alcohol based hand rub dispensers were mounted directly above an electrical outlet.