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Based on record review and interview, the facility failed to develop policies and procedures of the role of the facility under a waiver declared by the Secretary of Health and Human Services, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials, as required by 42 CFR 485.625(b)(8). This deficient practice could affect all residents, staff, and visitors.

Findings include:

During record review with the Director of Plant Operations and Director of Nursing on 08/20/18 at 11:50 a.m. no documentation could be found ensuring the facility developed policies and procedures of the role of the facility under a waiver declared by the Secretary of Health and Human Services, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management. Based on interview at the time of record review, the Director of Plant Operations and Director of Nursing stated they were unfamiliar with the 1135 Waiver and that there was no policy in place.

Based on observation and interview, the facility failed to ensure 2 of 12 of smoke barrier doors would restrict the movement of smoke for at least 20 minutes. LSC 19.2.1 requires healthcare occupancies to comply with LSC Chapter 7. Doors in smoke barriers are self-closing and kept in the closed position unless held open by a release device complying with 7.2.1.8.2. LSC 7.2.1.8.2 states that automatic releasing mechanism is activated by the operation of approved smoke detectors. CMS requires corridor doors to be positively latching and that if the door-set has an astragal attached, a coordinating device must be installed to ensure the appropriate door closes first. This deficient practice could affect all building occupants.

Findings include:

During a tour of the facility with the Director of Plant Operations on 08/20/18, the following were observed:
1) The Kitchen delivery double-doors, which is part of the A/B smoke barrier did not have a self-closing device or coordinator to ensure the proper door closed first.
2) The Kitchen delivery double-doors did not positively latch into the frame when closed.
3) The Laboratory Lounge Room, which is part of the B/C smoke barrier was propped open by a chair.
Based on interview at the time of observations, the Director of Plant Operations agreed that the kitchen door did not self-close, and that the door to the Laboratory lounge was propped open.

Based on observation, record review, and interview, the facility failed to maintain 3 of 3 operating or procedure room's battery operated emergency lights in accordance with NFPA 99, 2012 Edition, Section 6.3.2.2.11. Section 6.3.2.2.11.1 requires that locations where deep sedation and general anesthesia is administered be protected by one or more battery operated emergency lights. Section 6.3.2.2.11.5 requires that such units shall be tested monthly for 30 seconds and annually for 30 minutes. This deficient practice could affect staff and up to 3 patients.

Findings include:

During record review with the Director of Plant Operations on 08/20/18 from 8:30 a.m. to 1:30 p.m., no documentation could be found regarding monthly or annual testing of the emergency lighting in the operating or procedure rooms. Based on a review of the building electrical prints, battery operated emergency lights were in both operating rooms and the procedure room. Based on observation with the Director of Surgery on the same date between 1:30 p.m. and 4:30 p.m. battery operated emergency lighting was found in the operating and procedure rooms. Based on interview at the time of record review, the Director of Plant Operations confirmed the presence of battery operated emergency lighting in the ORs, and that no monthly or annual testing was conducted.

Based on record review and interview, the facility failed to ensure the humidity in 2 of 4 anesthetizing locations were maintained between 20% and 60%. NFPA 99 9.3.1.1 requires heating, cooling, ventilating, and process systems serving spaces or providing health care functions covered by this code or listed within ASHRAE 170, Ventilation of Health Care Facilities. ASHRAE 170, requires mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 20 percent or greater. CMS requires Operating Rooms not to exceed 60% humidity per S&C 13-25-LSC. This deficient practice could affect staff and up to 2 patients.

Findings include:

Based on record review with the Director of Plant Operations and Director of Surgery on 08/20/18 a.m., the operating room humidity was found out of the appropriate range on 144 of 253 daily recordings taken during the most recent twelve month period. Internal policy "Surg. 119" states that Operating Room humidity levels will be maintained at 20% - 60% in regard to infection control standards. No documentation could be located or provided indicating a response was performed when the humidity levels were out of range. No other further documentation was available to show what response was performed. Based on interview at the time of record review, the Director of Surgery stated that humidity is recorded only when procedures are planned, not on a daily basis. During interview, the Director of Plant Engineering acknowledged the aforementioned condition and stated when humidity is out of range, a work order should be generated, however he could provide no work orders regarding humidity levels during the same timeframe.

Based on observation and interview, the facility failed to ensure 1 of 1 fire alarm systems was installed in accordance with 19.3.4.1. NFPA 72, 17.7.4.1 requires in spaces served by air handling systems, detectors shall not be located where air flow prevents operation of the detectors. A.17.7.4.1 states detectors should not be located in a direct airflow or closer than 36 inches from an air supply diffuser or return air opening. This deficient practice could affect up to 10 patients and staff in the MRI Center and adjacent smoke compartment.

Findings include:

During a facility tour with the Director of Plant Operations on 08/20/18 at 3:45 p.m., the smoke detectors located in the MRI Machine Room were within an area where air flow would prevent operation of the detectors. Due to the high force air flow created by the MRI machine blowers, no smoke detectors were located in a place which would allow them to operate as required. Based on interview at the time of observation, the Director of Plant Operations agreed that the level of air movement would interfere with the proper operation of the smoke detectors.

Based on record review and interview, the facility failed to provide a complete 1 of 1 written policy for the protection of residents 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, as required by LSC Section 19.3.4.5.1 which requires an automatic smoke detection system in accordance with Section 9.6. This deficient practice affects all occupants.
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Findings include:

During record review with the Director of Plant Operations and Director of Nursing on 08/20/18 between 8:30 a.m. and 1:30 p.m., the facility provided fire watch plan documentation but it was incomplete. The plan failed to include contacting the Indiana State Department of Health via the ISDH Gateway link at https://gateway.isdh.in.gov as the primary method or by the secondary method when the ISDH Gateway is nonoperational by completing the Incident Reporting form and e-mailing it to incidents@isdh.in.gov. Based on interview during the record review, the Director of Plant Operations acknowledged the fire watch documentation provided named "Fire Watch" stated to contact the Indiana State Department of Health at a phone number, and not via the ISDH Gateway link or at the e-mail address listed above.

Based on observation and interview, the facility failed to provide ceiling construction in 1 of 1 MRI mechanical room in accordance with NFPA 13. The ceiling tiles trap hot air and gases around the sprinkler and cause the sprinkler to operate at a specified temperature. NFPA 13, 2010 edition, 8.5.4.11 states the distance between the sprinkler deflector and the ceiling above shall be selected based on the type of sprinkler and the type of construction. This deficient practice could affect up to 10 patients and staff in the MRI Center and adjacent smoke compartment.

Findings include:

During a facility tour with the Director of Plant Operations on 08/20/18 at 3:45 p.m. it was discovered that the MRI Machine Room was missing 6 of 50 ceiling tiles due to the arrangement of conduit and cables. During interview at the time of observation, the Director of Plant Operations acknowledged the missing ceiling tiles.

1) Based on record review and interview, the facility failed to document sprinkler system inspections in accordance with NFPA 25. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.4.1 states gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained. Section 5.2.4.2 states gauges on dry pipe sprinkler systems shall be inspected weekly to ensure that normal air and water pressures are being maintained. Section 5.1.2 states valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 13. Section 13.1.1.2 states Table 13.1.1.2 shall be utilized for inspection, testing and maintenance of valves, valve components and trim. Section 4.3.1 states records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request. This deficient practice could affect all patients, staff, and visitors.

Findings include:

During record review with the Director of Plant Operations from 8:30 a.m. to 1:30 p.m. on 08/20/18, weekly Pre-Action (dry) sprinkler system gauge inspection documentation for 52 weeks of the most recent 52 week period was not available for review. Monthly wet sprinkler system gauge inspection documentation for 12 months of the most recent 12 month period was also not available for review. In addition, monthly inspection documentation for all sprinkler system control valves for 12 months of the most recent 12 month period was not available for review. Based on interview at the time of record review, the Director of Plant Operations acknowledged sprinkler system gauge and control valve inspection documentation for the aforementioned weekly and monthly periods was not available for review.

2) Based on record review and interview, the facility failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 1 of 4 quarters. LSC 4.6.12.1 requires any device, equipment or system required for compliance with this Code be maintained in accordance with applicable NFPA requirements. Sprinkler systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 4.3.1 requires records shall be made for all inspections, tests, and maintenance of the system components and shall be made available to the authority having jurisdiction upon request. 4.3.2 requires that records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date. NFPA 25, 5.2.5 requires that waterflow alarm devices shall be inspected quarterly to verify they are free of physical damage. NFPA 25, 5.3.3.1 requires the mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly. 5.3.3.2 requires vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually. This deficient practice could affect all patients, staff, and visitors in the facility.

Findings include:

During record review of the quarterly sprinkler system inspection records on 08/20/18 at 11:39 a.m. with the Director of Plant Operations present, there was no quarterly sprinkler system inspection report available for the second quarter (April, May, June) of 2018. During an interview at the time of record review, the Director of Plant Operations acknowledged there was no written documentation available to show the sprinkler system had been inspected during the second quarter of 2018.

Based on record review and interview, the facility failed to provide a complete written policy containing procedures to be followed during the impairment of 1 of 1 automatic sprinkler system for 10 hours or more in a 24-hour period in accordance with LSC Section 9.7. as required by LSC Section 19.3.5.1. LSC 9.7.6 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. A.15.5.2 (6) states the insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified. This deficient practice could affect all occupants in the facility.

Findings include:

During record review with the Director of Plant Operations and Director of Nursing on 08/20/18 between 8:30 a.m. and 1:30 p.m., the facility provided fire watch plan documentation but it was incomplete. The plan failed to include contacting the Indiana State Department of Health via the ISDH Gateway link at https://gateway.isdh.in.gov as the primary method or by the secondary method when the ISDH Gateway is nonoperational by completing the Incident Reporting form and e-mailing it to incidents@isdh.in.gov. Based on interview during the record review, the Director of Plant Operations acknowledged the fire watch documentation provided named "Fire Watch" stated to contact the Indiana State Department of Health at a phone number, and not via the ISDH Gateway link or at the e-mail address listed above.

Based on observation and interview, the facility failed to ensure the penetrations caused by the passage of wire and/or conduit through 1 of 3 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 up to 20 patients in the adjacent "B and C" smoke compartments.

Findings include:

During a tour of the facility with the Maintenance Assistant #1 and Maintenance Assistant #2 on 08/21/18 at 8:47 a.m. two penetrations were found on the B/C Smoke barrier above the ceiling tiles between the Laboratory and Surgery Staff Lounge door. Specifically, a 2 inch stubbed conduit was not properly sealed, nor a 1/2 inch annular gap around conduit. At the time of observation, Maintenance Assistant #1 confirmed the two penetrations and agreed with the measurements.

Based on record review, observation and interview, the facility failed to ensure 1 of 1 emergency generator was protected in accordance with NFPA 110. NFPA 110, 2010 Edition defines an Emergency Power Supply (EPS) at Section 3.3.4, as the source of electric power of the required capacity and quality for an emergency power supply system (EPSS). Section 3.3.5 defines an EPSS as a complete functioning EPS system coupled to a system of conductors, disconnecting means and overcurrent protective devices, transfer switches, and all control, supervisory, and support devices up to and including the load terminals of the transfer equipment needed for the system to operate as a safe and reliable source of electric power. Section 7.3.1 requires that Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access. This deficient practice could affect all patients and staff in the facility.

Findings include:

Based on observation with the Director of Plant Operations on 08/20/18 at 3:19 p.m., battery powered emergency lighting was not provided at the automatic transfer switch location. Based on interview at the time of observation, the Director of Plant Operations confirmed the facility had a Level 1 EPS and agreed that the automatic transfer switch location did not include battery powered emergency lighting.

Based on observation and interview, the facility failed to ensure 1 of 1 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 only.

Findings include:

Based on observation with the Director of Plant Operations on 08/20/18 at 3:58 p.m. a surge protector was found powering a microwave and a toaster in the Emergency Department break room. Based on interview at the time of observation, the Director of Plant Operations agreed that the surge protector was powering high-amperage devices