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Based on observation and interview, the facility failed to ensure 1 of 5 exit accesses were provided with handrail. LSC 7.2.2.4.2 requires stairs and ramps shall have handrails on both sides. In addition, handrails shall be provided within 30 inches of all portions of the required egress width of stairs. The required egress width shall be provided along the natural path. Exception # 3 says Existing stairs, existing ramps stairs within dwelling units and within guest rooms shall be permitted to have a handrail on one side only. This deficient practice affects any patients using the emergency room exit during an evacuation.

Findings include:

Based on observation on 09/15/10 at 12:20 p.m. with the facility manager, the emergency room stairway exit had a ten foot long sloping sidewalk which was not provided with handrail on either side of the sidewalk leading to the parking lot. Based on an interview with the facility manager on 09/15/10 at 12:30 p.m., the sloping sidewalk had at least a three foot fall for the entire length of the sidewalk before the sidewalk discharged into the parking lot.

Based on record review and interview, the facility failed to provide a complete written policy containing 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 to protect 27 of 27 patients in accordance with LSC, Section 9.7.6.1. LSC 9.7.6.2 requires sprinkler impairment procedures comply with NFPA 25, 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 affects all patients in the facility.

Findings include:

Based on record review with the facility manager on 09/15/10 at 10:15 a.m., the facility's written Fire Watch Policy and Procedure did not include the notification of the local fire department and the Indiana State Department of Health. This was verified by the facility manager at the time of record review.

Based on record review and interview, the facility failed to provide a complete written policy for the protection of 27 of 27 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 24 hour period in accordance with LSC, Section 9.6.1.8. LSC, 19.7.1.1 requires every health care occupancy to have in effect and available to all supervisory personnel a plan for the protection of all persons. All employees shall periodically be instructed and kept informed with respect to their duties under the plan. The provisions of 19.7.1.2 through 19.7.2.3 shall apply. 19.7.2.2 requires all fire safety plans to provide for the use of alarms, the transmission of the alarm to the fire department and response to alarms. 19.7.2.3 requires health care personnel to be instructed in the use of a code phrase to assure transmission of the alarm during a malfunction of the building fire alarm system. This deficient practice affect all patients in the facility.

Findings include:

Based on record review with the facility manager on 09/15/10 at 10:15 a.m., the facility's written Fire Watch Policy and Procedure did not include the notification of the local fire department and the Indiana State Department of Health. This was verified by the facility manager at the time of record review.