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1. Based on observation and interview, the facility failed to ensure the 6 of 200 corridor doors latched into the door frames and would resist the passage of smoke. This deficient practice could affect at least 10 patients, staff and visitors on the second floor, all patients on the third floor behavior unit, and all patients, staff and visitors who use the basement canteen.

Findings include:

Based on observations with the HVAC-Plant Operations and Tech-Plant Operations staff and Director of Facilities from 10:30 a.m. to 1:30 p.m. on 06/03/14, the following was noted:
a. The door to room 367 did not latch into the frame.
b. The door to room 217 did not latch into the frame.
c. The door to the basement sterilizer room had a two inch gap along the latching side of the door in the closed position.
d. The door to the basement housekeeping storage room had two, one half inch circular holes through the door next to the door knob.
e. The double doors to the hyperbaric chamber room failed to positively latch into the door frame and had a manual slide bolt latch at the top of each door.
f. The door to room 246 failed to latch into the door frame on several attempts and left a one inch gap when closed. This was verified by the HVAC-Plant Operations staff, Tech-Plant Operations staff, and Director of Facilities at the time of observations and acknowledged by the Executive Director at the exit conference on 06/03/14 at 2:45 p.m.

2. Based on observation and interview, the facility failed to ensure 4 of 200 doors protecting corridor openings did not have an impediment to closing. This deficient practice could affect at least 10 patients, staff and visitors on the second floor, all patients on the third floor behavior unit, and all patients on the first floor emergency room.

Findings include:

Based on observations with the HVAC-Plant Operations staff and Tech-Plant Operations staff from 10:00 a.m. to 2:45 p.m. on 06/03/14, the following was noted:
a. The door to room 350 (office) was propped open with a wooden wedge under the door.
b. The door to the Behavioral Health Services office was propped open with a wooden wedge under the door.
c. The door to the first floor ER Treatment room was propped open with a wooden wedge under the door.
d. The door to room 310 was propped open with a wooden chair.
This was verified by the HVAC-Plant Operations and Tech-Plant Operations staff at the time of observation, and acknowledged by the Executive Director at the exit conference on 06/03/14 at 2:45 p.m. open.

Based on observation and interview, the facility failed to maintain the vertical opening protection for 2 of 4 basement exit stairwells. LSC 8.2.5.2 requires enclosure of vertical openings including stairwells with fire barrier walls with a fire resistance rating of at least one hour. This deficient practice could affect any patient, staff and visitor.

Findings include:

Based on observations on 06/03/14 during a tour of the basement with the Director of Facilities from 10:00 a.m. to 2:45 p.m., the kitchen stairway door and the canteen area stairway door each failed to self close and latch into the door frame, leaving a one inch gap along the latching side of the doors. This was verified by the Director of Facilities at the time of observations and acknowledged by the Executive Director at the exit conference on 06/03/14 at 2:45 p.m.

Based on observations and interview, the facility failed to ensure 2 of 3 basement sets of smoke barrier doors and 1 of 9 third floor sets of smoke barrier doors would restrict the movement of smoke for at least 20 minutes. LSC 19.3.7.6 requires doors in smoke barriers shall comply with LSC Section 8.3.4. LSC 8.3.4.1 requires doors in smoke barrier shall close the opening leaving only the minimum clearance necessary for proper operation which is defined as 1/8 inch. This deficient practice could affect patients as well as staff and visitors.

Finding include:

Based on observations with the Director of Facilities on 06/03/14 during a tour of the basement from 10:00 a.m. to 2:45 p.m., the set of smoke barrier doors by the pharmacy and the set of smoke barrier doors by the linen room failed to close completely, leaving a one inch gap where each set of doors came together. Furthermore, based on observation with the HVAC-Plant Operations and Tech-Plant Operations staff at 10:30 a.m. on 06/03/14, a door closer on one of the third floor sets of smoke barrier doors in the corridor near room 363 was disconnected and would not self close to form a smoke resistive barrier. The basement pharmacy, basement linen room and near room 363 on the third floor sets of smoke barrier doors not closing completely was verified by the Director of Facilities and HVAC-Plant Operations and Tech-Plant Operations staff at the time of observations and acknowledged by the Executive Director at the exit conference on 06/03/14 at 2:45 p.m.

Based on observation and interview, the facility failed to ensure the corridor doors to 1 of 10 third floor and 2 of 6 basement hazardous areas, such as an area exceeding 50 square feet and storing combustible materials, and 1 of 1 gas fired equipment rooms were provided with self closing devices which would cause the doors to automatically close and latch into the door frames. This deficient practice could affect patients, staff and visitors using the basement canteen, and any patients, staff and visitors using the third floor Respiratory Therapy area.

Findings include:

a. Based on observations on 06/03/14 during a tour of the third floor with the HVAC-Plant Operations and Tech-Plant Operations staff on 06/03/14 at 10:30 a.m., the third floor Respiratory Therapy Storage room (Room #375) door lacked a self closing device. This room exceeded 50 square feet and was used for storage of respiratory supplies wrapped in plastic and stored in cardboard boxes.
b. Based on observation with the Director of Facilities during a tour of the basement from 10:00 a.m. to 2:45 p.m., the basement's gas fired boiler room set of doors failed to self close and latch into the door frame on three separate attempts. The one hundred and forty square foot pharmacy storage room where twenty two cardboard boxes of pharmacy supplies were stored, and the sixty square foot copy machine room where eighteen plastic copy machines and six cardboard boxes filled with printer cartridges were stored each lacked self closing devices on the doors. This was verified by the HVAC-Plant Operations and Tech-Plant Operations staff and Director of Facilities at the time of observations and acknowledged by the Executive Director at the exit conference on 06/03/14 at 2:45 p.m.

Based on observation and interview; the facility failed to ensure 2 of 2 battery operated emergency lights in the Physical Therapy addition were maintained and functioned in accordance with LSC 7.9. LSC 7.9.2.5 requires the emergency lighting system shall be either continuously in operation or shall be capable of repeated automatic operation. LSC 7.9.3, Periodic Testing of Emergency Lighting Equipment, requires a functional test to be conducted for 30 seconds at 30 day intervals and an annual test to be conducted on every required battery powered emergency lighting system for not less than a 1 ? hour duration. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. This deficient practice could affect any patient, staff or visitor using the Physical Therapy addition.

Findings include:

Based on observation with the HVAC-Plant Operations and Tech-Plant Operations staff from 10:30 a.m. to 1:30 p.m. on 06/03/14, the two battery operated emergency lights in the Physical Therapy addition did not function when tested. Based on interview at the time of observation, the HVAC-Plant Operations and Tech-Plant Operations staff verified the aforementioned battery operated emergency lights did not function when tested. This was acknowledged by the Executive Director at the exit conference on 06/03/14 at 2:45 p.m.

Based on record review and interview, the facility failed to ensure fire drills were held at unexpected times, at least quarterly on 1 of 3 shifts during the past year. This deficient practice affects all patients, staff, and visitors.

Findings include:

Based on review of the Fire Drill Evacuation/Fire Report Checklist with the Director of Facilities on 06/03/14 at 10:15 a.m., fire drills conducted on the third shift were held at the following similar times: on 01/24/14 at 6:15 a.m., on 04/10/14 at 6:30 a.m., and on 07/09/13 at 6:30 a.m. Based on an interview with the Director of Facilities on 06/03/14 at 10:30 a.m., the third shift starts at 11:00 p.m. and ends at 7:00 a.m. The third shift fire drills being held at similar times was verified by the Director of Facilities at the time of record review and acknowledged by the Executive Director at the exit conference on 06/03/14 at 2:45 p.m.

1. Based on record review and interview, the facility failed to ensure 42 of 67 smoke detectors tested for sensitivity were either cleaned and recalibrated, or replaced. NFPA 72, National Fire Alarm Code, at 7-3.2 requires testing in accordance with Table 7-3.2, Testing Frequencies. Table 7-3.2.15(i) refers to 7-3.2.1 which requires Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate the detector had remained within its listed and marked sensitivity range, the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure each detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.
This deficient practice affects all patients, staff and visitors.

Findings include:

Based on a review of Koorsen Fire & Security Detector Sensitivity Test Reports dated 09/17/12 and 09/25/12 with the Director of Facilities on 06/03/14 at 10:30 a.m., the reports listed fifty seven smoke detectors which failed sensitivity testing. Furthermore, the Koorsen Fire & Security Service Work Order report dated 07/14/13 indicated the Tech Replaced 15 Smoke Detectors, but the report was not specific as to which smoke detectors had been replaced. Based on an interview with the Director of Facilities on 06/03/14 at 10:40 a.m., it was stated the facility is replacing the failed smoke detectors over time because of the cost involved with replacement. The forty two failed smoke detectors not being replaced or recalibrated was verified by the Director of Facilities at the time of record review, and acknowledged by the Executive Director at the exit conference on 06/03/14 at 2:45 p.m.

2. Based on observation and interview, the facility failed to ensure 3 of 67 smoke detectors in the facility connected to the fire alarm system were properly separated from an air supply or return vent. NFPA 72, National Fire Alarm Code, 2-3.5.1 requires spaces served by air handling systems, detectors shall not be located where airflow prevents operation of the detectors. This deficient practice could affect at least 10 patients as well as staff and visitors.

Findings include:

Based on observations with the HVAC-Plant Operations and Tech-Plant Operations staff from 10:30 a.m. to 1:30 p.m. on 06/03/14, the following was noted:
a. A smoke detector located in the third floor TV room was situated between a supply air vent and a make up air vent and was one foot away from either vent.
b. A smoke detector located in the third floor soiled linen room was one foot from an air supply vent.
c. A smoke detector located in the third floor personal laundry room was two feet from an air supply vent.
Based on interview at the time of observation, the HVAC-Plant Operations and Tech-Plant Operations staff verified the distances between the vents, and agreed the air flow could interfere with smoke detector function. This was acknowledged by the Executive Director at the exit conference on 06/03/14 at 2:45 p.m.

Based on record review, observation and interview; the facility failed to ensure 3 of 3 sprinkler system gauges were replaced or recalibrated every 5 years. NFPA 25, 2-3.2 requires gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced. This deficient practice affects all patients, staff and visitors.

Findings include:

Based on a review of Quarterly Sprinkler System Inspection Reports from 03/17/14 through 01/03/13 with the Director of Facilities on 06/03/14 at 10:40 a.m., there was no record the three sprinkler system gauges had been replaced over the past five years. Based on observation of the sprinkler riser, located in the basement boiler room on 06/03/14 at 10:45 a.m. with the Director of Facilities, there were three gauges on the sprinkler riser with a manufacturer date of 2008 on two gauges and no manufacturer date on the one gauge. The lack of the three sprinkler system gauges being replaced every five years was verified by the Director of Facilities at the time of observation of the sprinkler system riser and acknowledged by the Executive Director at the exit conference on 06/03/14 at 2:45 p.m.

Based on observation and interview, the facility failed to ensure a policy and procedure was available for the operation 1 of 1 space heaters to ensure the unit was equipped with a heating element which would not exceed 212 degrees Fahrenheit (F). This deficient practice would not affect patients but could affect staff.

Findings include:

Based on observation with the HVAC-Plant Operations and Tech-Plant Operations staff from 10:30 a.m. to 1:30 p.m. on 06/03/14, a portable space heater was plugged into an electrical outlet and appeared to be in use in the medical staff office. The HVAC-Plant Operations and Tech-Plant Operations staff said at the time of observation, they were unaware there was a space heater in the facility. They were unaware of a policy and procedure for the use of space heaters to identify where they might be used and any restrictions related to their use in the facility. This was acknowledged by the Executive Director at the exit conference on 06/03/14 at 2:45 p.m.

Based on observation and interview, the facility failed to ensure the means of egress was continuously maintained free of impediments to full instant use in the case of fire or other emergency for 1 of 3 exits. This deficient practice could affect any patient, staff or visitor using the south exit stairwell in the event of an emergency.

Finding include:

Based on observation with the HVAC-Plant Operations and Tech-Plant Operations staff from 10:30 a.m. to 1:30 p.m. on 06/03/14, the bushes outside the south exit were overgrown and protruding into the exit discharge path, covering half of the sidewalk. Based on interview at the time of observation, the HVAC-Plant Operations and Tech-Plant Operations staff verified the means of egress was not continuously maintained free of impediments at the south exit. This was acknowledged by the Executive Director at the exit conference on 06/03/14 at 2:45 p.m.

Based on record review and interview, the facility failed to ensure 1 of 10 inspection certificates was current to ensure the water heater was in safe operating condition. NFPA 101, in 19.1.1.3 requires all health facilities to be maintained and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants. This deficient practice could affect all patients, staff and visitors.

Findings include:

Based on review of the ten boiler/hot water heater inspection certificates with the Director of Facilities on 06/03/14 at 11:05 a.m., the inspection certificate for the Lochnivar model hot water heater with the Indiana Registration #281834 had an expiration date of 03/14/13.
Based on an interview with the Director of Facilities on 06/03/14 and observation of the Lochnivar model water heater located in the basement boiler room, there was no current inspection certificate in the boiler room. The lack of a current inspection certificate for the Lochnivar model hot water heater was verified by the Director of Facilities at the time of record review and acknowledged by the Executive Director at the exit conference on 06/03/14 at 2:45 p.m.

1. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was 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 the patients as well as visitors and staff.

Findings include:

Based on observation on 06/03/14 at 12:10 p.m. during a tour of the facility with HVAC/Plant Operations and Tech/Plant Operations staff, there was no remote alarm annunciator for the emergency generator in a location readily observed by operating personnel at a regular work station such as a nurses' station. Furthermore, the only remote alarm annunciator for the generator was located in the Business Office which was not occupied at all times. This was verified by HVAC/Plant Operations and Tech/Plant Operations staff at the time of observation who confirmed the Business Office was not occupied at all times, and acknowledged by the Executive Director at the exit conference on 06/03/14 at 2:45 p.m.

2. Based on observation and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with a remote manual stop. LSC 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 1999 edition, 3-5.5.6 requires Level II installations shall have a remote manual stop station of a type similar to a break-glass station located elsewhere on the premises where the prime mover is located outside the building. 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 in the facility.

Findings include:

Based on observations on 06/03/14 between 10:30 a.m. and 2:00 p.m. during a tour of the facility with HVAC/Plant Operations and Tech/Plant Operations staff, a remote shut off device for the generator was not found. Based on interview at 12:22 p.m. while at the generator, the HVAC/Plant Operations staff person said the generator was over 150 Horsepower and verified there was no remote shut off device for the generator. This was acknowledged by the Executive Director at the exit conference on 06/03/14 at 2:45 p.m.

Based on observation and interview, the facility failed to ensure flexible cord electrical wiring used in the business office was in accordance with NFPA 70, National Electrical Code. NFPA 70, Article 400-8 requires flexible cords and cables shall not be used for the following:
1. As a substitute for the fixed wiring of a structure.
2. Where run through holes in the walls, structural ceilings, suspended ceilings, dropped ceilings; or floors.
3. Where run through doorways, windows, or similar openings.
4. Where attached to building surfaces.
5. Where concealed behind walls, structural ceilings, dropped ceilings or floors.
6. When installed in raceways, except otherwise permitted in this Code.
This deficient practice could affect any patient, staff or visitor using the 1st floor main corridor.

Findings include:

Based on observation on 06/03/14 during a tour of the facility from 10:30 a.m. to 1:30 p.m. with the HVAC-Plant Operations and Tech-Plant Operations staff, there was 15 foot length of orange electrical cord that was plugged into an electrical outlet in the Business office and went up the wall, under the lay-in ceiling tile and was spliced into an electrical cord with a switch that was attached to a light at the top of a curio cabinet built into the first floor main corridor wall. Based on interview at the time of observation, the HVAC-Plant Operations and Tech-Plant Operations staff acknowledged the orange electrical cord in the business office. This was acknowledged by the Executive Director at the exit conference on 06/03/14 at 2:45 p.m.