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Based on record review 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. This deficient practice could affect any occupant in the "E" building and Block wing.

Findings include:

Based on review of a Fire Safety Evaluation System (FSES) Fire Safety Features Record Drawings dated 02/22/2013 with the Regional Director of Engineering, the Vice President of Engineering and the Director of Engineering on 03/05/14 from 9:30 a.m. to 2:30 p.m., 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. Based on 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.

Based on record review and interview, the facility 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. This deficient practice could affect any occupant in the "E" building and Block wing.

Findings include:

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

Based on record review and interview, the facility 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. LSC 19.2.4.1 states not less than two exits of the types described in 19.2.2.2 through 19.2.2.10, remotely located form each other, shall be provided for each floor or fire section of the building 2 of 4 buildings. LSC 19.2.2.4 states smokeproof enclosures complying with LSC 7.2.3 shall be permitted. LSC 7.2.3.5 states every smokeproof enclosure shall discharge into a public way, into a yard or court having direct access to a public way, or into an exit passageway. Such exit passageways shall be without openings other than the entrance from the smokeproof enclosure and the door to the outside yard, court or public way. The exit passageway shall be separated from the remainder of the building by a 2 hour fire resistance rating. This deficient practice affects any occupant in the "E" building and Block wing.

Findings include:

Based on review of a Fire Safety Evaluation System (FSES) Fire Safety Features Record Drawings dated 02/22/2013 with the Regional Director of Engineering, the Vice President of Engineering and the Director of Engineering on 03/05/14 from 9:30 a.m. to 2:30 p.m., exit stairs in the "E" building and Block wing do not discharge to the outside or through an approved exit passageway. Based on 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..

Based on record review and interview the facility failed to ensure the travel distance to an exit does not exceed 150 feet in 2 of 4 buildings. This deficient practice could affect any occupant in the "E" building and Block wing.

Findings include:

Based on review of a Fire Safety Evaluation System (FSES) Fire Safety Features Record Drawings dated 02/22/2013 with the Regional Director of Engineering, the Vice President of Engineering and the Director of Engineering on 03/05/14 from 9:30 a.m. to 2:30 p.m., the travel distance to an exit exceeds 150 feet in Zones 1B and 1J. Based on interview at the time of 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.

Based on record review and interview the facility failed to ensure the width of aisles or corridors serving as exit access was at least four feet in 2 of 4 buildings. This deficient practice could affect any occupant in the "E" building and Block wing.

Findings include:

Based on review of a Fire Safety Evaluation System (FSES) Fire Safety Features Record Drawings dated 02/22/2013 with the Regional Director of Engineering, the Vice President of Engineering and the Director of Engineering on 03/05/14 from 9:30 a.m. to 2:30 p.m., the corridor width was reduced to less than four feet in Zones 1F and 1J. Based on 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.

Based on observation and interview, the facility failed to provide exterior emergency lighting for 28 of 31 exits. LSC Section 7.9.1.1 requires emergency lighting for means of egress shall be provided for the exit access and exit discharge. This deficient practice could affect all occupants throughout the facility if forced to evacuate.

Findings include:

Based on observation with the Regional Director of Engineering, the Vice President of Engineering and the Director of Engineering during a tour of the facility on 03/06/14 from 8:15 a.m. to 12:00 p.m., battery operated lights were not being used for the exterior lighting. Based on interview on 03/06/14 at 3:00 p.m., the Director of Engineering 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.

Based on observation and interview, the facility failed to ensure sprinklers in areas where cubicle curtains in 25 of 25 patient rooms on the 5th floor Acute Rehab Unit were provided in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. This deficient practice could affect at least 25 patients.

Findings include:

Based on observation with the Regional Director of Engineering, the Vice President of Engineering and the Director of Engineering during a tour of the facility on 03/06/14 from 8:15 a.m. to 12:00 p.m., 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. Based on interview at the time of the exit conference, the Director of Engineering confirmed there were 25 patient rooms on the 5th floor Acute Rehab Unit with private bathroom shower curtains with no mesh top panel.

Based on observation and interview, the facility failed to electronically supervise 2 of 10 sprinkler valves in the Physician's Office Building (POB). LSC Section 9.7.2.1 requires supervisory attachments to be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code and a distinctive supervisory signal to be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. This deficient practice could affect all occupants in the POB building, if the water to the sprinkler system was shut off and not detected due to lack of supervision.

Findings include:

Based on observation with the Director of Engineering on 03/06/14 from 1:00 p.m. to 2:00 p.m., 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. Based on interview at the time of observation, the Director of Engineering acknowledged the two sprinkler OS & Y valves lacked electronic supervision.

Based on record review and interview, the facility failed to ensure 3 of 3 fire pumps were provided with an adequate and reliable water supply for the automatic sprinkler system. The deficient practice would affect all occupants.

Findings include:

Based on observation with the Director of Engineering on 03/06/14 from 1:00 p.m. to 2:00 p.m., 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. Based on interview at the time of observation, the Director of Engineering acknowledged the two sprinkler OS & Y valves lacked electronic supervision.

1. Based on record review and interview, the facility 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. NFPA 96, 1998 Edition
Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, Section 7-4.1 requires upon activation of any fire extinguishing system for a cooking operation, all sources of fuel and electric power that produce heat to all equipment requiring protection by that system shall automatically shut off. This deficient practice could affect any staff in the kitchen or staff and visitors who use the main dining room located adjacent to the kitchen.

Findings include:

Based on 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 the Engineering Quality Coordinator, the reports had no verification of natural gas and/or electrical shut off testing for the two inspections. Based on interview from 8:15 a.m. to 12:00 p.m. on 03/06/14 with the Director of Engineering, a natural gas and /or electrical shutoff for the main cooking area and serving line cooking area fire suppression systems could not be verified.

2. Based on observation and interview, the facility failed to install and maintain 2 of 2 kitchen hood exhaust systems in accordance with the requirements of NFPA 96, 1998 Edition, the Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Section 3-1 states listed grease filters, baffles, or other approved grease removal devices for use with commercial cooking equipment shall be provided. Listed grease filters shall be tested in accordance with UL 1046, Grease Filters for Exhaust Ducts. Section 8-1.2 states filter equipped exhaust systems shall not be operated with filters removed. This deficient practice could affect any staff in the kitchen or staff and visitors who use the main dining room located adjacent to the kitchen.

Findings include:

Based on observation on 03/06/14 from 8:15 a.m. to 12:00 p.m. with the Regional Director of Engineering, the Vice President of Engineering and the Director of Engineering, 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." Based on interview at the time of of observation, the Director of Food and Nutrition 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.

Based on observation and interview, the facility failed to enforce it's space heater policy in employee areas for the use of 1 of 1 portable space heaters in the facility in accordance with NFPA 101, Section 19.7.8. This deficient practice could affect any number of patients, staff and visitors throughout the facility.

Findings include:

Based on observation with the Director of Engineering during a tour of the facility on 03/05/14 from 2:30 p.m. to 4:30 p.m., a space heater was observed plugged into a power source and operating in the third floor West Clinical Case Manager's office. Based on interview at the time of observation, the Director of Engineering 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.

1. Based on observation and interview, 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 nurses' station. NFPA 99, Health Care Facilities, 3-4.1.1.15 requires a remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
1. When the emergency or auxiliary power source is operating to supply power to load.
2. When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate:
1. Low lubricating oil pressure.
2. Low water temperature.
3. Excessive water temperature.
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply.
5. Overcrank (failed to start).
6. Overspeed.
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur but need not display these conditions individually. This deficient practice could affect all occupants.

Findings include:

Based on observation on 03/06/14 from 8:15 a.m. to 12:00 p.m. with the Director of Engineering Services, remote alarm annunciators for the two generators were not provided in a location readily observed by operating personnel at a regular work station. Based on interview at the time of observation, the Director of Engineering acknowledged the lack of generator remote annunciators at a regular work station and indicated the generators are slated to be replaced in several months and will have compliant annunciators.

2. Based on observation and interview, the facility failed to ensure 2 of 2 emergency generators with over 100 horsepower was equipped with a remote manual stop. NFPA 110, 1999 edition, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for shutting down the engine at the engine and from a remote location. This deficient practice could affect all occupants.

Findings include:

Based on observation on 03/06/14 from 8:15 a.m. to 12:00 p.m. with the Director of Engineering, 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. Based on an interview at the time of observation, the Director of Engineering acknowledged each of the generator engines provide more than 100 horsepower and lack remote manual stop stations. Furthermore, the Director of Engineering indicated the generators are slated to be replaced in several months and will have compliant remote manual stop stations.

1. Based on observation and interview, the facility failed to ensure ground fault circuit interrupter (GFCI) receptacles on 4 of 7 floors were provided and operated properly to protection against electric shock. NFPA 70, Article 517, Health Care Facilities, defines wet locations as patient care areas subjected to wet conditions while patients are present. These include standing fluids on the floor or drenching of the work area, either of which condition is intimate to the patient or staff. NFPA 70, 517-20 Wet Locations, requires all receptacles and fixed equipment within the area of the wet location to have GFCI protection. Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice could affect any occupant throughout the hospital.

Findings include:

Based on observations with the Regional Director of Engineering, the Vice President of Engineering and the Director of Engineering 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., 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. Based on interview at the times of observation, the Regional Director of Engineering, the Vice President of Engineering and the Director of Engineering acknowledged the aforementioned wet location areas were not provided with GFCI protection.

2. Based on observation and interview, the facility 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. LSC 19.5.1 requires utilities to comply with Section 9.1. LSC 9.1.1 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 1999 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. This deficient practice could affect any occupant throughout the hospital.

Findings include:

Based on observation with the Director of Engineering during a tour of the facility on 03/05/14 from 2:30 p.m. to 4:30 p.m., a microwave, toaster oven and a toaster were plugged into power strip in the 5th floor West employee locker room. Based on interview at the times of observation, the Director of Engineering acknowledged the aforementioned condition.

Based on record review and interview, the facility 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 in accordance with LSC, Section 9.7.6.1. in order to protect 103 of 103 patients. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, 1998 Edition, Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 11-5(d) requires the local fire department be notified of a sprinkler impairment and 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified. This deficient practice could affect all occupants.

Findings include:

Based on 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, 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. Based on interview at the time of record review, the Engineering Quality Coordinator acknowledged the fire watch policy and procedure did not include notification to the Indiana State Department of Health.

Based on record review and interview, the facility 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 in accordance with LSC, Section 9.6.1.8. in order to protect 103 of 103 patients. This deficient practice could affect all occupants of the facility.

Findings include:

Based on 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, 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. Based on interview at the time of record review, the Engineering Quality Coordinator acknowledged the fire watch policy and procedure did not include notification to the Indiana State Department of Health.

Based on observation and interview, the facility failed to ensure 10 of 10 alcohol based hand rub dispensers within the Intensive Care Unit (ICU) were not installed over an ignition source. This deficient practice could affect any patient within the ICU as well as staff and visitors.

Findings include:

Based on observation and interview on 03/05/14 with the Vice President of Engineering during the tour from 2:30 p.m. to 4:30 p.m., the ten ICU rooms had an alcohol based hand rub dispenser mounted on the corridor wall directly above an electrical outlet. Based on interview with the Vice President of Engineering, it was acknowledge the alcohol based hand rub dispensers were mounted directly above an electrical outlet.

Based on record review 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. This deficient practice could affect any occupant in the "E" building and Block wing.

Findings include:

Based on review of a Fire Safety Evaluation System (FSES) Fire Safety Features Record Drawings dated 02/22/2013 with the Regional Director of Engineering, the Vice President of Engineering and the Director of Engineering on 03/05/14 from 9:30 a.m. to 2:30 p.m., 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. Based on 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.

Based on record review and interview, the facility 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. This deficient practice could affect any occupant in the "E" building and Block wing.

Findings include:

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

Based on record review and interview, the facility 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. LSC 19.2.4.1 states not less than two exits of the types described in 19.2.2.2 through 19.2.2.10, remotely located form each other, shall be provided for each floor or fire section of the building 2 of 4 buildings. LSC 19.2.2.4 states smokeproof enclosures complying with LSC 7.2.3 shall be permitted. LSC 7.2.3.5 states every smokeproof enclosure shall discharge into a public way, into a yard or court having direct access to a public way, or into an exit passageway. Such exit passageways shall be without openings other than the entrance from the smokeproof enclosure and the door to the outside yard, court or public way. The exit passageway shall be separated from the remainder of the building by a 2 hour fire resistance rating. This deficient practice affects any occupant in the "E" building and Block wing.

Findings include:

Based on review of a Fire Safety Evaluation System (FSES) Fire Safety Features Record Drawings dated 02/22/2013 with the Regional Director of Engineering, the Vice President of Engineering and the Director of Engineering on 03/05/14 from 9:30 a.m. to 2:30 p.m., exit stairs in the "E" building and Block wing do not discharge to the outside or through an approved exit passageway. Based on 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..

Based on record review and interview the facility failed to ensure the travel distance to an exit does not exceed 150 feet in 2 of 4 buildings. This deficient practice could affect any occupant in the "E" building and Block wing.

Findings include:

Based on review of a Fire Safety Evaluation System (FSES) Fire Safety Features Record Drawings dated 02/22/2013 with the Regional Director of Engineering, the Vice President of Engineering and the Director of Engineering on 03/05/14 from 9:30 a.m. to 2:30 p.m., the travel distance to an exit exceeds 150 feet in Zones 1B and 1J. Based on interview at the time of 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.

Based on record review and interview the facility failed to ensure the width of aisles or corridors serving as exit access was at least four feet in 2 of 4 buildings. This deficient practice could affect any occupant in the "E" building and Block wing.

Findings include:

Based on review of a Fire Safety Evaluation System (FSES) Fire Safety Features Record Drawings dated 02/22/2013 with the Regional Director of Engineering, the Vice President of Engineering and the Director of Engineering on 03/05/14 from 9:30 a.m. to 2:30 p.m., the corridor width was reduced to less than four feet in Zones 1F and 1J. Based on 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.

Based on observation and interview, the facility failed to provide exterior emergency lighting for 28 of 31 exits. LSC Section 7.9.1.1 requires emergency lighting for means of egress shall be provided for the exit access and exit discharge. This deficient practice could affect all occupants throughout the facility if forced to evacuate.

Findings include:

Based on observation with the Regional Director of Engineering, the Vice President of Engineering and the Director of Engineering during a tour of the facility on 03/06/14 from 8:15 a.m. to 12:00 p.m., battery operated lights were not being used for the exterior lighting. Based on interview on 03/06/14 at 3:00 p.m., the Director of Engineering 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.

Based on observation and interview, the facility failed to ensure sprinklers in areas where cubicle curtains in 25 of 25 patient rooms on the 5th floor Acute Rehab Unit were provided in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. This deficient practice could affect at least 25 patients.

Findings include:

Based on observation with the Regional Director of Engineering, the Vice President of Engineering and the Director of Engineering during a tour of the facility on 03/06/14 from 8:15 a.m. to 12:00 p.m., 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. Based on interview at the time of the exit conference, the Director of Engineering confirmed there were 25 patient rooms on the 5th floor Acute Rehab Unit with private bathroom shower curtains with no mesh top panel.

Based on observation and interview, the facility failed to electronically supervise 2 of 10 sprinkler valves in the Physician's Office Building (POB). LSC Section 9.7.2.1 requires supervisory attachments to be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code and a distinctive supervisory signal to be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. This deficient practice could affect all occupants in the POB building, if the water to the sprinkler system was shut off and not detected due to lack of supervision.

Findings include:

Based on observation with the Director of Engineering on 03/06/14 from 1:00 p.m. to 2:00 p.m., 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. Based on interview at the time of observation, the Director of Engineering acknowledged the two sprinkler OS & Y valves lacked electronic supervision.

Based on record review and interview, the facility failed to ensure 3 of 3 fire pumps were provided with an adequate and reliable water supply for the automatic sprinkler system. The deficient practice would affect all occupants.

Findings include:

Based on observation with the Director of Engineering on 03/06/14 from 1:00 p.m. to 2:00 p.m., 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. Based on interview at the time of observation, the Director of Engineering acknowledged the two sprinkler OS & Y valves lacked electronic supervision.

1. Based on record review and interview, the facility 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. NFPA 96, 1998 Edition
Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, Section 7-4.1 requires upon activation of any fire extinguishing system for a cooking operation, all sources of fuel and electric power that produce heat to all equipment requiring protection by that system shall automatically shut off. This deficient practice could affect any staff in the kitchen or staff and visitors who use the main dining room located adjacent to the kitchen.

Findings include:

Based on 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 the Engineering Quality Coordinator, the reports had no verification of natural gas and/or electrical shut off testing for the two inspections. Based on interview from 8:15 a.m. to 12:00 p.m. on 03/06/14 with the Director of Engineering, a natural gas and /or electrical shutoff for the main cooking area and serving line cooking area fire suppression systems could not be verified.

2. Based on observation and interview, the facility failed to install and maintain 2 of 2 kitchen hood exhaust systems in accordance with the requirements of NFPA 96, 1998 Edition, the Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Section 3-1 states listed grease filters, baffles, or other approved grease removal devices for use with commercial cooking equipment shall be provided. Listed grease filters shall be tested in accordance with UL 1046, Grease Filters for Exhaust Ducts. Section 8-1.2 states filter equipped exhaust systems shall not be operated with filters removed. This deficient practice could affect any staff in the kitchen or staff and visitors who use the main dining room located adjacent to the kitchen.

Findings include:

Based on observation on 03/06/14 from 8:15 a.m. to 12:00 p.m. with the Regional Director of Engineering, the Vice President of Engineering and the Director of Engineering, 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." Based on interview at the time of of observation, the Director of Food and Nutrition 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.

Based on observation and interview, the facility failed to enforce it's space heater policy in employee areas for the use of 1 of 1 portable space heaters in the facility in accordance with NFPA 101, Section 19.7.8. This deficient practice could affect any number of patients, staff and visitors throughout the facility.

Findings include:

Based on observation with the Director of Engineering during a tour of the facility on 03/05/14 from 2:30 p.m. to 4:30 p.m., a space heater was observed plugged into a power source and operating in the third floor West Clinical Case Manager's office. Based on interview at the time of observation, the Director of Engineering 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.

1. Based on observation and interview, 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 nurses' station. NFPA 99, Health Care Facilities, 3-4.1.1.15 requires a remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
1. When the emergency or auxiliary power source is operating to supply power to load.
2. When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate:
1. Low lubricating oil pressure.
2. Low water temperature.
3. Excessive water temperature.
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply.
5. Overcrank (failed to start).
6. Overspeed.
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur but need not display these conditions individually. This deficient practice could affect all occupants.

Findings include:

Based on observation on 03/06/14 from 8:15 a.m. to 12:00 p.m. with the Director of Engineering Services, remote alarm annunciators for the two generators were not provided in a location readily observed by operating personnel at a regular work station. Based on interview at the time of observation, the Director of Engineering acknowledged the lack of generator remote annunciators at a regular work station and indicated the generators are slated to be replaced in several months and will have compliant annunciators.

2. Based on observation and interview, the facility failed to ensure 2 of 2 emergency generators with over 100 horsepower was equipped with a remote manual stop. NFPA 110, 1999 edition, 3-5.5.6 requires Level I installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for shutting down the engine at the engine and from a remote location. This deficient practice could affect all occupants.

Findings include:

Based on observation on 03/06/14 from 8:15 a.m. to 12:00 p.m. with the Director of Engineering, 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. Based on an interview at the time of observation, the Director of Engineering acknowledged each of the generator engines provide more than 100 horsepower and lack remote manual stop stations. Furthermore, the Director of Engineering indicated the generators are slated to be replaced in several months and will have compliant remote manual stop stations.

1. Based on observation and interview, the facility failed to ensure ground fault circuit interrupter (GFCI) receptacles on 4 of 7 floors were provided and operated properly to protection against electric shock. NFPA 70, Article 517, Health Care Facilities, defines wet locations as patient care areas subjected to wet conditions while patients are present. These include standing fluids on the floor or drenching of the work area, either of which condition is intimate to the patient or staff. NFPA 70, 517-20 Wet Locations, requires all receptacles and fixed equipment within the area of the wet location to have GFCI protection. Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice could affect any occupant throughout the hospital.

Findings include:

Based on observations with the Regional Director of Engineering, the Vice President of Engineering and the Director of Engineering 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., 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. Based on interview at the times of observation, the Regional Director of Engineering, the Vice President of Engineering and the Director of Engineering acknowledged the aforementioned wet location areas were not provided with GFCI protection.

2. Based on observation and interview, the facility 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. LSC 19.5.1 requires utilities to comply with Section 9.1. LSC 9.1.1 requires electrical wiring and equipment to comply with NFPA 70, National Electrical Code, 1999 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. This deficient practice could affect any occupant throughout the hospital.

Findings include:

Based on observation with the Director of Engineering during a tour of the facility on 03/05/14 from 2:30 p.m. to 4:30 p.m., a microwave, toaster oven and a toaster were plugged into power strip in the 5th floor West employee locker room. Based on interview at the times of observation, the Director of Engineering acknowledged the aforementioned condition.

Based on record review and interview, the facility 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 in accordance with LSC, Section 9.7.6.1. in order to protect 103 of 103 patients. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, 1998 Edition, Standard for Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 11-5(d) requires the local fire department be notified of a sprinkler impairment and 11-5(e) requires the insurance carrier, alarm company, building owner/manager and other authorities having jurisdiction also be notified. This deficient practice could affect all occupants.

Findings include:

Based on 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, 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. Based on interview at the time of record review, the Engineering Quality Coordinator acknowledged the fire watch policy and procedure did not include notification to the Indiana State Department of Health.

Based on record review and interview, the facility 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 in accordance with LSC, Section 9.6.1.8. in order to protect 103 of 103 patients. This deficient practice could affect all occupants of the facility.

Findings include:

Based on 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, 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. Based on interview at the time of record review, the Engineering Quality Coordinator acknowledged the fire watch policy and procedure did not include notification to the Indiana State Department of Health.