HospitalInspections.org

A Life Safety Code Validation Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 482.41(b).

Survey Date: 02/06/18 and 02/07/18

Facility Number: 009443

At this Life Safety Code Validation Survey, Select Specialty Hospital-Evansville was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.

This facility was a four story building with a basement and was determined to be of Type II (222) construction and was fully sprinkled. The facility has a fire alarm system with hard wired smoke detectors in the corridors, spaces open to the corridors, and all patient sleeping rooms. The facility has a capacity of 60 and had a census of 50 at the time of this survey.

All areas where patients have customary access were sprinkled and all areas providing facility services were sprinkled.

Based on record review, observation and interview, the facility failed to provide a complete facility specific written fire safety plan for the protection of 50 of 50 patients to accurately address all life safety systems (see tag K711), the facility failed to ensure at least 20 of over 50 sprinkler heads in the old laundry room and maintenance area of the basement were free of corrosion (see tag K353 #2), the facility failed to ensure at least 12 of 300 smoke detectors were not installed where air flow would adversely affect its operation (see tag K341), the facility failed to provide a complete written policy for the protection of 50 of 50 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 (see tag K346), the facility failed to provide a written policy containing procedures to be followed for the protection of 50 of 50 residents in the event the automatic sprinkler system has to be placed out-of-service for 10 hours or more in a 24-hour period (see tag K354), the facility failed to ensure 1 of at least 7 sets of corridor doors would close to form a smoke resistant barrier (see tag K374), the facility failed to ensure 3 of over 25 wet locations were provided with ground fault circuit interrupter (GFCI) protection against electric shock (see tag K511), the facility failed to ensure 1 of 1 emergency generator was provided with an alarm annunciator in a location readily observed by operating personnel at a regular work station such as a nurses' stations (see tag K916).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on document review and interview, the QAPI (Quality Assurance Performance Improvement) program failed to provide evidence that each quality indicator selected in the past 4 quarters was related to improved health outcomes and failed to specify frequency and detail of data collection for 7 of 23 indicators (discharge planning, endoscopy, ICU (intensive care unit), PICC (peripherally inserted central catheter) services, diagnostic radiology, respiratory care and wound care) for 1 facility.

Findings include:

1. Review of the Quality Assessment and Performance Improvement Plan (QAPI), Revised January 2017, indicated the following:
A. Use appropriate statistical techniques to measure performance and display data
B. Outcomes will be measured at specific intervals.
C. The frame of reference for interpreting the collected data will be: internal trends and comparisons over time; comparison of hospitals within...and comparison with external organizations nationally.

2. Review of QAPI meeting minutes dated 11/3/17, 8/11/17, 5/5/17 and 2/10/17 together with documents titled 2016 Quality Improvement Program Evaluation, Annual Contract Services Review and Department Performance Improvement Matrix lacked documentation of basis for selection of any indicators and lacked documentation of frequency and detail of data collection for the indicators of discharge planning, endoscopy, ICU, PICC services, diagnostic radiology, respiratory care or wound care.

3. On 2/7/18, between approximately 10:45am and 11:30am, A4, Director of Quality Management, verified the program did not have documentation of basis for selection of indicators and that indicators for discharge planning, endoscopy, ICU, PICC services, diagnostic radiology, respiratory care and wound care lacked clear detail of specifics for frequency and method of data collection.

Based on document review, observation and interview, the facility failed to follow policy/procedure to ensure that patient information is not viewable to unauthorized individuals for 1 (4th Floor Unit) of 5 areas toured.

Findings include:

1. Policy H04-A, Safeguarding Protected Health Information (PHI), revised/reapproved 02/04/2016 indicated on page 2: "Computer screens containing patient information, including patient billing information should be located so that they are not in the view of the public or people passing by".

2. While on tour of facility on 2/7/18 at approximately 1100 hours, in the presence of staff N1, patient medical record (MR) information was viewable without staff members present on 2 computer screens located on workstations on wheels (WOW) in the hallway of the 4th floor unit.

3. Staff N1 (House Supervisor) was interviewed on 2/7/18 at approximately 1100 hours and confirmed patient MR information was viewable and unattended on computer screens located on WOWs in the hallway of the 4th floor unit and accessible to unauthorized persons and persons not involved with the patients' care.

Based on document review, observation and interview, the facility failed to ensure nursing staff followed established policies/procedures regarding safe storage of medications in 1 (4th Floor Unit) of 5 areas toured.

Findings include:

1. Policy/procedure: D14-P, Security of Medication Storage Areas, revised/reapproved 7/2011 indicated: "All medication carts shall remain locked at all times when not attended. This shall include the time required for a nurse to enter a patient's room to administer a medication".

2. While on tour of the 4th Floor Unit on 2/7/18 at approximately 1045 hours, accompanied by staff N1, 2 Workstations on Wheels (WOW) located in the patient hallway were observed to contain medications in drawers that were unlocked.

3. Staff N1 (House Supervisor) was interviewed on 2/7/18 at approximately 1100 hours and confirmed 2 WOWs located in the patient hallway on the 4th Floor Unit contained medications that were accessible to unauthorized individuals. Staff N1 confirmed staff were not following policies/procedures for medication storage and security.

Based on observation and interview, the facility failed to ensure at least 12 of 300 smoke detectors were not installed where air flow would adversely affect its operation. NFPA 72, 2010 edition, 17.7.6.3.2 requires that smoke detectors shall not be located directly in the airstream of supply registers. Section 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 more than 10 patients, as well as staff and visitors, the facility failed to provide a complete written policy for the protection of 50 of 50 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 in the facility, the facility failed to provide a written policy containing procedures to be followed for the protection of 50 of 50 residents 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 in the facility, the facility failed to ensure 1 of at least 7 sets of corridor doors would close to form a smoke resistant barrier. Centers for Medicare & Medicaid Services (CMS) requires sets of smoke barrier doors which swing in the same direction and equipped with an astragal to have a coordinator to ensure the door which must close first always closes first. This deficient practice could potentially affect patients, as well as staff and visitors on the 2nd floor, the facility failed to ensure 3 of over 25 wet locations were provided with ground fault circuit interrupter (GFCI) protection against electric shock. NFPA 70, NEC 2011 Edition at 210.8 Ground-Fault Circuit-Interrupter Protection for Personnel, states, ground-fault circuit-interruption for personnel shall be provided as required in 210.8(A) through (C). The ground-fault circuit-interrupter shall be installed in a readily accessible location.
Informational Note: See 215.9 for ground-fault circuit interrupter protection for personnel on feeders.
(B) Other Than Dwelling Units. All 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified in 210.8(B)(1) through (8) shall have ground-fault circuit-interrupter protection for personnel.
(1) Bathrooms
(2) Kitchens
(3) Rooftops
(4) Outdoors
Exception No. 1 to (3) and (4): Receptacles that are not readily accessible and are supplied by a branch circuit dedicated to electric snow-melting, deicing, or pipeline and vessel heating equipment shall be permitted to be installed in accordance with 426.28 or 427.22, as applicable.
Exception No. 2 to (4): In industrial establishments only, where the conditions of maintenance and supervision ensure that only qualified personnel are involved, an assured equipment grounding conductor program as specified in 590.6(B)(2) shall be permitted for only those receptacle outlets used to supply equipment that would create a greater hazard if power is interrupted or having a design that is not compatible with GFCI protection.
(5) Sinks - where receptacles are installed within 1.8 m (6 ft.) of the outside edge of the sink.
Exception No. 1 to (5): In industrial laboratories, receptacles used to supply equipment where removal of power would introduce a greater hazard shall be permitted to be installed without GFCI protection.
Exception No. 2 to (5): For receptacles located in patient bed locations of general care or critical care areas of health care facilities other than those covered under
210.8(B)(1), GFCI protection shall not be required.
(6) Indoor wet locations
(7) Locker rooms with associated showering facilities
(8) Garages, service bays, and similar areas where electrical
diagnostic equipment, electrical hand tools.
NFPA 70, 517-20 Wet Locations, requires all receptacles and fixed equipment within the area of the wet location to have ground-fault circuit interrupter (GFCI) protection. Note: Moisture can reduce the contact resistance of the body, and electrical insulation is more subject to failure. This deficient practice could affect staff only.

Findings include:

1. Based on observations on 02/06/18 between 3:00 p.m. and 4:15 p.m. and 02/07/18 between 10:30 a.m. and 3:00 p.m. during a tour of the facility with the Director of Plant Operations, the following ceiling mounted smoke detectors were too close to air supply and return vents:
a. The smoke detector in the maintenance storage/locker room in the basement was within 8 inches of an air return vent
b. The smoke detector in the Financial Services office in the basement was within 8 inches of an air supply vent
c. The smoke detector in the 4th floor east-west corridor on the west side of the smoke barrier doors was within 12 inches of an air supply vent
d. The smoke detector in room 412 was within 12 inches of an air supply vent
e. The smoke detector in the 3rd floor Procedure Room was within 12 inches of an air supply vent
f. The smoke detector in the 3rd floor Pharmacy was within 6 inches of an air supply vent
g. The smoke detector in the 2nd floor corridor west of the nurses' station was within 6 inches of an air supply vent
h. The smoke detector room 211 was within 12 inches of an air supply vent
i. The smoke detector in the 1st floor Radiology Room was within 8 inches of an air supply vent
j. The smoke detector in the 1st floor Vending Machine room was within 12 inches of an air supply vent
k. Two smoke detectors in the 1st floor Triage Room hall were within 12 inches of two separate air supply vents
Based on interview at the time of each observation, the Director of Plant Operations agreed the smoke detector in question were all too close to air return and air supply vents.

2. Based on record review on 02/06/18 at 11:40 a.m. with the Director of Plant Operations present, the facility provided fire watch documentation, however, it was incomplete. The plan failed to include the following:
a. The web link for contacting the Incident Reporting System located on the Indiana State Department of Health Gateway
b. The phone number for the local fire department
c. Contacting the facility's insurance carrier with phone number
d. The statement indicating the only duty the fire watch person has is the fire watch
e. The fire watch policy also did not include documentation to indicate the person conducting the fire watch has been properly trained. Based on an interview at the time of record review, the Director of Plant Operations agreed the fire watch policy lacked the previously mentioned information.

3. Based on record review on 02/06/18 at 11:40 a.m. with the Director of Plant Operations present, the facility provided fire watch documentation, however, it was incomplete. The plan failed to include the following:
a. The web link for contacting the Incident Reporting System located on the Indiana State Department of Health Gateway
b. The phone number for the local fire department
c. Contacting the facility's insurance carrier with phone number
d. The statement indicating the only duty the fire watch person has is the fire watch
e. The fire watch policy also did not include documentation to indicate the person conducting the fire watch has been properly trained. Based on an interview at the time of record review, the Director of Plant Operations agreed the fire watch policy lacked the previously mentioned information.

4. Based on observation on 02/07/18 at 11:47 a.m. during a tour of the facility with the Director of Plant Operations, the set of smoke barrier doors near room 204 closed in the same direction with an astragal on one door. These doors and frame were not equipped with a coordinator to ensure that the door that's supposed to close first, does close first. Based on interview at the time of observation, the Director of Plant Operations said he was not aware the set of smoke barrier doors on the 2nd floor near room 204 required a coordinator.

5. Based on observations on 02/07/18 between 10:30 a.m. and 3:00 p.m. during a tour of the facility with the Director of Plant Operations, the following was noted:
a. There was one electric receptacle within two feet of the sink in the third floor staff locker room. The electric receptacle was not provided with ground fault circuit interrupters (GFCI). This was confirmed when tested with a GFCI testing device
b. There was one electric receptacle within two feet of the sink in the second floor staff lounge. The electric receptacle was not provided with ground fault circuit interrupters (GFCI). This was confirmed when tested with a GFCI testing device
c. There was one electric receptacle within two feet of the sink in the second floor Day Room. The electric receptacle was not provided with ground fault circuit interrupters (GFCI). This was confirmed when tested with a GFCI testing device
Based on interview at the time of each observation, the Director of Plant Operations agreed the receptacles in the previously mentioned rooms were not GFCI protected.

Based on record review and interview, the facility failed to provide a complete facility specific written fire safety plan for the protection of 50 of 50 patients to accurately address all life safety systems, plus a system addressing all items required by NFPA 101, 2012 edition, Section 19.7.2.2. 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
Section 19.2.3.4(4) states any required aisle or corridor shall not be less than 48 inches in clear width where serving as means of egress from patient sleeping rooms. Projections into the required width shall be permitted for wheeled equipment provided the relocation of wheeled equipment during a fire or similar emergency is addressed in the written fire safety plan and training program for the facility. The wheeled equipment is limited to:
i. Equipment in use and carts in use
ii. Medical emergency equipment not in use
iii. Patient lift and transport equipment
This deficient practice could affect all occupants in the event of an emergency.

Findings include:

Based on a review of the Fire Plan on 02/06/18 at 11:48 a.m. with the Director of Plant Operations present, the fire safety plan did not address the following issues:
a. The transmission of the alarm to the fire department
b. A back up call to the fire department (911) after the fire alarm system has been activated
c. Isolation of the fire
d. The evacuation of the smoke compartment
e. Location of smoke/fire barriers
f. The use of the K-class fire extinguisher in the kitchen in relationship with the use of the kitchen overhead extinguishing system
Based on interview at the time of record review, the Director of Plant Operations agreed that the fire plan reviewed was not a complete fire safety plan.

Based on observation and interview, the facility failed to ensure at least 20 of over 50 sprinkler heads in the old laundry room and maintenance area of the basement were free of corrosion. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems at 5.2.1.1.1 requires sprinklers to be free of paint and corrosion. 5.2.1.1.2 requires any sprinkler that shows signs of paint or corrosion shall be replaced. This deficient practice could affect staff only, the facility failed to ensure 1 of 1 emergency generator was provided with an alarm annunciator in a location readily observed by operating personnel at a regular work station such as a nurses' stations. NFPA 99, 2012 Edition, Health Care Facilities Code, at 6.4.1.1.17 requires a remote annunciator that is 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 be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows:
(1) Individual visual signals shall indicate:
a. When the emergency or auxiliary power source is operating to supply power to load.
b. When the battery charger is malfunctioning.
(2) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate:
a. Low lubricating oil pressure.
b. Low water temperature.
c. Excessive water temperature.
d. Low fuel when the main fuel storage tank contains less than a 4-hour operating supply.
e. Overcrank (failed to start).
f. 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 6.4.1.1.17(1) and (2) occur but need not display these conditions individually. This deficient practice could affect all patients, as well as visitors and staff in the facility.

Findings include:

Based on observations on 02/06/18 between 3:00 p.m. and 4:15 p.m. during a tour of the facility with the Director of Plant Operations, the following was noted:
a. 12 sprinkler heads in the old laundry room was covered with corrosion
b. 8 sprinkler head in the maintenance area were covered with corrosion
Based on interview at the time of observations, the Director of Plant Operations agreed the previously mentioned sprinkler heads were covered with corrosion.

Based on interview during record review on 02/06/18 at 3:00 p.m., the Director of Plant Operations said the facility has an emergency generator. When asked, the Director of Plant Operations said there was no remote alarm annunciator panel for the generator at a 24 hour station, such as a nurses' station. This was confirmed during a tour of the facility with the Director of Plant Operations on 02/06/18 between 3:00 p.m. and 4:15 p.m. and on 02/07/18 between 10:30 a.m. and 3:00 p.m., there was no remote alarm annunciator panel for the generator at any nurses' station.