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Based on record review and interview, the facility failed to ensure the emergency preparedness communication plan includes (2) Contact information for the following: (i) Federal, State, tribal, regional, or local emergency preparedness staff (ii) Other sources of assistance in accordance with 42 CFR 482.15(c)(2). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Chief Nursing Officer, COO, and Plant Operations #1 on 08/27/18 at 4:10 p.m., the emergency preparedness communication plan failed to include contact information for (i) Federal, State, tribal, regional, or local emergency preparedness staff or (ii) Other sources of assistance. Based on interview at the time of record review, the Chief Nursing Officer, COO, and Plant Operations #1 confirmed no further documentation was available for review.

Based on record review and interview, the facility failed to ensure the emergency preparedness communication plan includes (4) A method for sharing information and medical documentation for patients under the hospital's care, as necessary, with other health care providers to maintain the continuity of care; (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii); (6) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4) in accordance with 42 CFR 482.15(c)(4). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Chief Nursing Officer, COO, and Plant Operations #1 on 08/27/18 at 4:12 p.m., the emergency preparedness plan failed to include a communication plan that included a method for sharing information and medical documentation for residents under the Hospital's care, as necessary, with other health care providers to maintain the continuity of care. Based on interview at the time of record review, the Chief Nursing Officer, COO, and Plant Operations #1 confirmed no further documentation was available for review.

Based on record review and interview, the facility failed to ensure the emergency preparedness communication plan includes a means of providing information about the hospital's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction or the Incident Command Center, or designee in accordance with 42 CFR 482.15(c)(7). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Chief Nursing Officer, COO, and Plant Operations #1 on 08/27/18 at 4:17 p.m., a communication plan that included a means of providing information about the hospital's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction or the Incident Command Center, or designee in accordance with 42 CFR 483.73(c)(7) was not available for review. Based on interview at the time of record review then again at the exit conference, the Chief Nursing Officer, COO, and Plant Operations #1 confirmed that the communication plan did not include the aforementioned occupancy, needs, and ability to provide assistance to the AHJ, IC, or designee.

Based on record review and interview, the facility failed to ensure the emergency preparedness training and testing program includes a training program. The hospital must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles; (ii) Provide emergency preparedness training at least annually; (iii) Maintain documentation of the training; (iv) Demonstrate staff knowledge of emergency procedures in accordance with 42 CFR 482.15(d)(1). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Chief Nursing Officer, COO, and Plant Operations #1 on 08/27/18 at 4:17 p.m., a training and testing program of emergency preparedness plan was not available for review. Based on interview at the time of record review then again during the exit conference, the Chief Nursing Officer, COO, and Plant Operations #1 confirmed that staff have not been trained specifically on emergency preparedness and no program has been set up.

Based on record review and interview, the facility failed to conduct exercises to test the emergency plan at least annually, including unannounced staff drills using the emergency procedures. The hospital must do all of the following: (i) participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the hospital experiences an actual natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in a community-based or individual, facility-based full-scale exercise for 1 year following the onset of the actual event; (ii) conduct an additional exercise that may include, but is not limited to the following: (A) a second full-scale exercise that is community-based or individual, facility-based. (B) a tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan; (iii) analyze the hospital's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the hospital's emergency plan, as needed in accordance with 42 CFR 482.15(d)(2). This deficient practice could affect all occupants.

Findings include:

Based on record review with the Chief Nursing Officer, COO, and Plant Operations #1 on 08/27/18 at 4:20 p.m., the facility participated in a full scale exercise but did not perform a tabletop drill or a second full scale exercise. Based on interview at the time of record review, the Chief Nursing Officer, COO, and Plant Operations #1 confirmed no tabletop drill was performed nor a second full scale exercise.

Based on observation and interview, the facility failed to maintain latching hardware on 1 of 2 ICU smoke barrier doors per 4.6.12.3. LSC 4.6.12.3 requires existing life safety features obvious to the public if not required by the Code, shall be either maintained or removed. This deficient practice could affect staff and 10 patients.

Findings include:

Based on observation with the COO and the Plant Operations #1 on 08/27/18 at 2:02 p.m. then again at 2:06 p.m., the ICU smoke barrier doors near the Telecom room #3 contained latching hardware. When tested, one of the smoke barrier doors failed to latch. Then again, the PreOp smoke barrier doors contained latching hardware. When tested, one of the smoke barrier doors failed to latch. Based on interview at the time of each observation, the COO and the Plant Operations #1 confirmed each one of the two smoke barriers door sets failed to latch.

Based on observation and interview, the facility failed to maintain 3 of 16 corridors from obstructions per 19.2.1 LSC 19.2.1 states that every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11. LSC 7.1.10. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. LSC 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto, egress therefrom, or visibility thereof. This deficient practice could affect staff and at least 11 patients.

Findings include:

Based on observation with the COO and the Plant Operations #1 on 08/27/18 between 1:50 a.m. and 2:21 p.m., the following was discovered:
a) a soiled linen cart was in the corridor outside patient room E-209
b) a soiled linen cart was in the corridor outside patient room W-101
c) two separate soiled linen carts and two carts with supplies were in the corridor near Electrical room 3
Based on interview at the time of each observation, the COO and the Plant Operations #1 acknowledged that impediments such as the soiled linen carts and supply carts were potential impediments to full use of the means of egress access corridors.

Based on observation and interview, the facility failed to ensure the means of egress through 1 of 3 ER exits were readily accessible. This deficient practice could affect staff and up to 3 patients.

Findings include:

Based on observation with the COO and the Plant Operations #1 on 08/27/18 at 2:46 p.m., the exterior sliding glass exit doors would not automatically open. Based on interview at the time of the observations, the ER staff indicated that they turned the automatic open feature off because it was letting hot air inside. The COO and the Plant Operations #1 confirmed they were unaware staff turned off the access-controlled egress doors automatic feature.

Based on observation and interview, 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, 14.2.1.2.2 requires that system defects and malfunctions shall be corrected. This deficient practice could affect all occupants.

Findings include:

Based on observation with the COO and the Plant Operations #1 on 08/27/18 at 1:17 p.m., the fire alarm annunciator panel indicated a trouble. The panel indicated the smoke detector in the B102 corridor south exit was dirty. Based on interview at the time of record review, the Maintenance Director acknowledged the issue and was unaware of the trouble alarm.

Based on record review and interview, the facility failed to provide a complete 1 of 1 written policy for the protection of patients 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 COO and the Plant Operations #1 on 08/27/18 at 10:47 a.m., the facility provided fire watch documentation but it was incomplete. The plan failed to include, the person conducting the fire watch shall be trained and contacting the Indiana State Department of Health via the Web Portal. Based on an interview at the time of record review, the COO and the Plant Operations #1 acknowledged fire watch policy failed to include the person conducting the fire watch shall be trained and 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 the ceiling construction in 1 of 1 sprinkler systems in accordance with 19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 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 and up to occupants.

Findings include:

Based on observation with the COO and the Plant Operations #1 on 08/27/18 at 1:21 p.m., the North Exit had a missing escutcheon near the exit door. Based on interview at the time of observation, the COO and the Plant Operations #1 acknowledged and confirmed the missing escutcheon.

Based on observation and interview, the facility failed to replace sprinkler heads in 1 of 1 sprinkler system in accordance with LSC 9.7.5. NFPA 25, 2011 edition, at 5.2.1.1.1 sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., up-right, pendent, or sidewall). Furthermore, at 5.2.1.1.2 any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (3) Physical Damage (4) Loss of fluid in the glass bulb heat responsive element (5) Loading (6) Painting unless painted by the sprinkler manufacturer. This deficient practice could affect staff only.

Findings include:

Based on observation with the COO and the Plant Operations #1 on 08/27/18 between 2:05 p.m. and 3:17 p.m., the following was discovered:
a) a sprinkler head was painted in the Electrical room #5
b) a sprinkler head was covered in a silver material in the Electrical room #3
c) a sprinkler head was painted in the Medical Gas room
Based on interview at the time of observation, the COO and the Plant Operations #1 acknowledged and confirmed each sprinkler head was painted or covered.

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 COO and the Plant Operations #1 on 08/27/18 at 10:47 a.m., the facility provided fire watch documentation but it was incomplete. The plan failed to include, the person conducting the fire watch shall be trained, contacting the insurance company, and contacting the Indiana State Department of Health via the Web Portal. Based on an interview at the time of record review, the COO and the Plant Operations #1 acknowledged fire watch policy failed to include the person conducting the fire watch shall be trained, contacting the insurance company, and including 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 ensure 1 of 3 E wing corridor was separated from the corridors by a partition capable of resisting the passage of smoke as required in a sprinklered building, or met an Exception per 19.3.6.1(7). LSC 19.3.6.1(7) states that spaces other than patient sleeping rooms, treatment rooms, and hazardous areas shall be open to the corridor and unlimited in area, provided: (a) The space and corridors which the space opens onto in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, and (b) Each space is protected by an automatic sprinklers, and (c) The space does not to obstruct access to required exits. This deficient practice could affect staff and at least 7 patients.

Findings include:

Based on observation with the COO and the Plant Operations #1 on 08/27/18 at 1:44 p.m., the Nourishment area was open to the corridor. Furthermore, LSC 19.3.6.1(7) was not met because the room was not protected by an electrically supervised automatic smoke detection system. Based on interview at the time of observation, the COO and the Plant Operations #1 confirmed the area is open to the corridor and no hardwired detector was installed.

Based on observation and interview, the facility failed to maintain protection of corridor doors in 1 of 6 W Hall corridors in accordance of 19.3.6.3. This deficient practice could affect staff and at least 4 patients.

Findings include:

Based on observation with the COO and the Plant Operations #1 on 08/27/18 at 2:19 p.m., a chair impeded patient room W-104 corridor door from closing. Based on interview at the time of observation, the COO and the Plant Operations #1 acknowledged the door was impeded from closing.

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 4 of 8 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 at least 7 patients.

Findings include:

Based on observations with the COO and the Plant Operations #1 on 08/27/18 between 3:51 p.m. and 4:15 p.m., the following unsealed penetrations were discovered:
a) a one inch gap around pipe above the drop ceiling in the ICU Entrance smoke barrier
b) a two inch by one and a half inch gap around HVAC above the drop ceiling in the smoke barrier near patient room W-103
c) a six inch gap above the drop ceiling in the ER Waiting room bathroom smoke barrier
d) a four inch gap inside conduit around wires above the drop ceiling in the OR to Cath Lab smoke barrier
Based on interview at the time of each observation, the COO and the Plant Operations #1 acknowledged each aforementioned condition and provided the measurements.

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
This deficient practice could affect all occupants.

Findings include:

Based on a record review and interview on 08/27/18 at 10:47 a.m., the COO and the Plant Operations #1 acknowledged the "Fire Response Plan" did not address (3) Emergency phone call to fire department.

1. Based on record review and interview, the facility failed to conduct quarterly fire drills for 1 of 4 quarters. LSC 19.7.1.6 requires drills to be conducted quarterly on each shift under varied conditions. This deficient practice affects all staff and patients.

Findings include:

Based on record review of titled "Security/Observer's Form For Fire Drill/Fire Alarm" with the COO and the Plant Operations #1 on 07/16/18 at 10:47 a.m., there was no documentation for a second shift fire drill in the third quarter of 2017. Based on interview at the time of record review, the COO and the Plant Operations #1 were unable to provide further documentation.

2. Based on record review and interview, the facility failed to ensure 8 of 8 fire drills shall be held at expected and unexpected times for under varying conditions to simulate the unusual conditions that can occur in an actual emergency for the last 4 quarters. This deficient practice affects all occupants.

Findings include:

Based on record review of titled "Security/Observer's Form For Fire Drill/Fire Alarm" with the COO and the Plant Operations #1 on 07/16/18 at 10:47 a.m., the documentation for the drills for the past twelve months failed to document simulation of emergency fire conditions. Based on interview at the time of record review, the COO and the Plant Operations #1 confirmed no documentation was available showing the simulation of emergency fire conditions.

3. Based on record review and interview, the facility failed to ensure 8 of 8 fire drills included the verification of transmission of the fire alarm signal and simulation of emergency fire conditions for the last 4 quarters. This deficient practice affects all patients in the facility as well as staff and visitors.

Findings include:

Based on record review of titled "Security/Observer's Form For Fire Drill/Fire Alarm" with the COO and the Plant Operations #1 on 07/16/18 at 10:47 a.m., the documentation for the drills for the past twelve months lacked verification of the transmission of the signal for drills. Additionally, documentation failed to include simulation of emergency fire conditions. Based on interview at the time of record review, the COO and the Plant Operations #1 confirmed no documentation was available showing the times when the monitoring company received the fire alarm signal.

Based on observation and interview, the facility failed to ensure 2 of 2 space heater was in accordance with 19.7.8. This deficient practice could affect staff and up to 13 patients.

Findings include:

Based on observation with the COO and the Plant Operations #1 on 08/27/18 at 1:27 p.m. then again at 2:55 p.m., a space heater was discovered in the Nurse Educator office. Then again, a space heater was discovered in the CT Staff area. Based on interview at the time of each observation, the COO and the Plant Operations #1 was unaware each space heater was in the building and confirmed no documentation was available to prove the heating element does not exceed 212 degrees.

1. Based on record review and interview, the facility failed to document the transfer time to the alternate power source on the monthly load tests for 12 of the past 12 months to ensure the alternate power supply was capable of supplying service within 10 seconds. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on record review with the COO and the Plant Operations #1 on 08/27/18 at 10:47 a.m., the monthly Generator Load Tests lacked the generator's transfer time from normal power to emergency power. Based on interview at the time of record review, the COO and the Plant Operations #1 acknowledged the lack of documentation.

2. 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 COO and the Plant Operations #1 on 08/27/18 at 10:47 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 COO and the Plant Operations #1 acknowledged the lack of documentation.

Based on observation and interview, the facility failed to ensure 6 of 6 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 up to 4 patients.

Findings include:

Based on observation with the COO and the Plant Operations #1 on 08/27/18 between 1:25 p.m. and 3:18 p.m., the following was discovered:
a) a surge protector was powering a coffee pot in the Human Resources office
b) an extension cord was powering a computer monitor in the Pharmacy
c) a surge protector was powering a refrigerator in the ER registration area
d) an extension cord powering a surge protector powering computer components in the Doctor's lounge
e) a surge protector powering a microwave in the Plant Operations office
Based on interview at the time of each observation, the COO and the Plant Operations #1 acknowledged and confirmed each wiring situation.