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Based on Life Safety Code (LSC) survey, Union Hospital Clinton, was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR 485.623(d), Life Safety from Fire and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies.

The two story facility was determined to be of Type II (222) construction and fully sprinklered. The facility has a fire alarm system with smoke detection in the corridors and spaces open to the corridors. The facility has the capacity for 25 patients and had a census of 11 patients.

Based on LSC survey and deficiencies found (see 2567L), it was determined that the facility failed to ensure 1 of 3 doors protecting corridor openings to the surgery/recovery room suite would latch into the door frame (See K 018), failed to ensure openings through smoke barriers on 2 of 2 floors were maintained to provide the 1/2 hour fire and smoke resistance of the smoke barriers (see K 025), failed to ensure 3 of 3 doors/partitions to hazardous areas such as a kitchen, closed automatically or upon activation of the fire alarm system, failed to ensure 1 of 12 hazardous areas such as the kitchen was separated from other spaces by a smoke resistant partition, failed to provide automatic closers for doors providing access to 1 of 4 second floor hazardous areas such as a combustible materials storage room larger than 50 square feet (see K 029), failed to ensure 2 of 13 exits were arranged so the exit discharged to a readily accessible public way at all times (see K 032), failed to ensure 2 of 5 first floor fire door sets were arranged to automatically close and latch (see K 044), failed to provide a fire plan which included the identification of and evacuation of the smoke compartments, the types of fire extinguishers available, or the use of the K-class fire extinguisher in conjunction with the overhead hood system in the written fire plan for the protection of all occupants (see K 048), failed to ensure 1 of 1 fire alarm panels in an area not continuously occupied was provided with automatic smoke detection to ensure notification of a fire at the location before it could be incapacitated by fire, failed to ensure smoke detectors connected to the fire alarm system in 2 of 7 first floor smoke compartments were properly separated from an air supply (see K 051), failed to ensure dampers in the ductwork serving 9 of 9 smoke compartments were inspected and and provided necessary maintenance at least every four years (see K 067), failed to provide the minimum protection between 2 of 2 commercial cooking appliances in the kitchen, failed to ensure 1 of 1 kitchen exhaust hoods, grease removal devices, fans, ducts, and other appurtenances were cleaned to bare metal at frequent intervals (see K 069), failed to ensure 2 of 2 generators serving as the alternate source of power were maintained and capable of automatically connecting to the load within 10 seconds in the event of failure of normal power, failed to ensure load monthly testing of the Level II generator was performed during 11 of the past 12 months using one of the three following methods: under operating temperature conditions, at not less than 30% of the Emergency Power Supply (EPS) nameplate rating, or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer (see K 144) and failed to ensure electrical outlets supplied by emergency power in 1 of 1 surgery and recovery room suites were readily identifiable and failed to ensure 3 of 3 flexible cords were not used as a substitute for fixed wiring (see K 147).

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 observation, record review and interview, the facility failed to ensure 1 of 3 doors protecting corridor openings to the surgery/recovery room suite would latch into the door frame, failed to ensure openings through smoke barriers on 2 of 2 floors were maintained to provide the 1/2 hour fire and smoke resistance of the smoke barriers, failed to ensure 3 of 3 doors/partitions to hazardous areas such as a kitchen, closed automatically or upon activation of the fire alarm system, failed to ensure 1 of 12 hazardous areas such as the kitchen was separated from other spaces by a smoke resistant partition, failed to provide automatic closers for doors providing access to 1 of 4 second floor hazardous areas such as a combustible materials storage room larger than 50 square feet, failed to ensure 2 of 13 exits were arranged so the exit discharged to a readily accessible public way at all times, failed to ensure 2 of 5 first floor fire door sets were arranged to automatically close and latch, failed to provide a fire plan which included the identification of and evacuation of the smoke compartments, the types of fire extinguishers available, or the use of the K-class fire extinguisher in conjunction with the overhead hood system in the written fire plan for the protection of all occupants, failed to ensure 1 of 1 fire alarm panels in an area not continuously occupied was provided with automatic smoke detection to ensure notification of a fire at the location before it could be incapacitated by fire, failed to ensure smoke detectors connected to the fire alarm system in 2 of 7 first floor smoke compartments were properly separated from an air supply, failed to ensure dampers in the ductwork serving 9 of 9 smoke compartments were inspected and and provided necessary maintenance at least every four years, failed to provide the minimum protection between 2 of 2 commercial cooking appliances in the kitchen, failed to ensure 1 of 1 kitchen exhaust hoods, grease removal devices, fans, ducts, and other appurtenances were cleaned to bare metal at frequent intervals, failed to ensure 2 of 2 generators serving as the alternate source of power were maintained and capable of automatically connecting to the load within 10 seconds in the event of failure of normal power, failed to ensure load monthly testing of the Level II generator was performed during 11 of the past 12 months using one of the three following methods: under operating temperature conditions, at not less than 30% of the Emergency Power Supply (EPS) nameplate rating, or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer and failed to ensure electrical outlets supplied by emergency power in 1 of 1 surgery and recovery room suites were readily identifiable and failed to ensure 3 of 3 flexible cords were not used as a substitute for fixed wiring.

Findings:

1. Observation with MPO1 on 11/14/12 between 10:00 a.m. and 4:00 p.m. indicated the corridor access door adjacent to offices in the surgery/recovery room suite had no latch to secure the door in the door frame. The door relied on an automatic door opening and closing system to secure the door in its frame, a conduit penetration of the smoke barrier door near surgery was unsealed leaving a half inch gap above the laid in corridor ceiling, two conduit penetrations above the laid in ceiling at the north smoke barrier doors near the lab were unsealed leaving one inch gaps between the two adjacent smoke compartments, a six by twelve inch cut out to allow the passage of cables and wires in the smoke barrier above the laid in ceiling between the emergency room and reception area was unsealed, an unsealed pipe penetration above the laid in ceiling at the smoke barrier separating the physical plant from the main hospital left a half inch gap, two unsealed penetrations of the east smoke barrier near the lab left half inch gaps, an unsealed penetration by cables through the smoke barrier wall near room 234 left a one inch gap above the laid in ceiling, cables running between the traction room into the space above the laid in ceiling displaced the ceiling tile leaving a half inch gap, three penetrations of the smoke barrier above the laid in ceiling near the back nurse station left unsealed gaps of one half to one inch, the cable penetration above the laid in ceiling in the smoke barrier near room 209 was unsealed and the smoke barrier above the laid in ceiling in the Special Care Unit near room 1 was unsealed leaving a one inch gap, two self closing doors between the kitchen and cafeteria had no latches and could not be held tightly in their door frames and a 24 by 24 inch opening between the cafeteria and kitchen was protected by a sliding steel partition which had to be manually closed, a six inch by eighteen inch opening between the cafeteria and kitchen provided a chute opening to dispose of dining waste the door separating the ten by eight foot IV supply storage room on the med-surg unit had no self closing device and the room was lined with shelves laden with cardboard and plastic wrapped supplies, two east stairway exits discharged onto three by three foot concrete slabs and discharge from the slabs required crossing a two foot area of round stones and then a grassy lawn to reach the public way, two fire door sets in the physical plant operations corridor were tested twice manually and one door in each fire door set failed to latch each time the doors were released to close, two corridor smoke detectors near the physical plant offices and general storage rooms and a third corridor smoke detector at the smoke barrier in the adjacent smoke compartment were located eight inches from air supply vents, electrical outlets in all areas of the surgery and recovery room suite had no distinct marking to identify those supplied with emergency power, two power strip extension cords were piggy backed to supply power to multiple computers and attached equipment and a power strip extension cord was used to supply power to a microwave, coffee pot and toaster in a storage room in the radiology department.

2. Review of the fire safety plan indicated there was no direction to remove endangered residents to another smoke compartment if indicated and no identification of smoke zones as places of refuge and their location. In addition, the fire safety plan did not identify available fire extinguishers and address the K-class fire extinguisher located in the kitchen in relationship with the use of the kitchen overhead extinguishing system.

3. Review of preventive maintenance records indicated records of smoke damper inspections by the facility maintenance crew was limited to monthly checks to ensure no obstruction to closing was evident. No record of a verification of their operation and maintenance performed was found and a record for cleaning the kitchen hood exhaust system duct was not found.

4. Review of Work Orders for testing Level I and Level II emergency generators indicated a generator load test was conducted one time in May 2012 during the past year on the Level II generator during a contracted load bank test.

5. MPO1 agreed with and confirmed the observations at the times of observations.

Based on document review, observation, and interview, the facility failed to remove soiled items from cleaned patient rooms for 2 of 2 rooms in the special care unit (SCU).

Findings include:

1. Facility policy titled "CLEANING PATIENT ROOM AFTER DISCHARGE/TRANSFER" last reviewed/revised 5/21/12 states under procedure: "Empty all waste containers. The waste containers will be wiped out with a hospital approved germicidal solution and bag liners replaced." The policy references cleaning and making the bed, however does not specify what to do with soiled linens.

2. During tour of the SCU beginning at 10:15 a.m. on 11/14/12 and accompanied by RN #1, the following was observed:
(A) Room #1, unoccupied and clean, had soiled linens in the linen hamper and trash in the trashcan.
(B) Room #2, unoccupied and clean, had soiled linens in the linen hamper.

3. RN #1 verified the above observations and indicated during the time of the tour that housekeeping is in charge of cleaning the rooms after a patient is discharged.