HospitalInspections.org

Based on document review and review of the Life Safety Code (LSC) complaint investigation findings (ASPEN #NTZC21; KS00179247) the Hospital failed to ensure the occupants in the Emergency Room were provided with two, clearly identified, exits from the Trauma Bay suite as required per 2012 National Fire Protection Agency 101, Life Safety Code, 18.2.5.2.

This deficient practice affects all staff and up to 6 patients who could become isolated in the Trauma Bay and could not exit the building safely during an emergency likely resulting in serious injury, serious harm, serious impairment, or death.

Findings Include:

Observation during the life safety code complaint investigation survey on 3/28/23 revealed the following:

1. The Hospital failed to meet the applicable provisions of the current LSC requirements when they failed to provide two clearly identifiable exits once outside the Trauma Bay. The Hospital modified the Emergency Room suite because of a construction project.

2. This survey finding resulted in an Immediate Jeopardy (IJ) (a situation in which entity noncompliance placed the health and safety of recipients in its care are at risk for serious injury, serious impairment, or death). The surveyor notified the hospital staff of the IJ on 3/28/23 at 1:00 PM. The hospital provided an approved plan of removal on 03/28/23 which included but is not limited to: "...the suite boundaries for the trauma suite will be extended to incorporate the corridor. The suite area with extended boundaries will have two means of egress once you exit-one through the hold opens going east and one through exterior sliding doors going south...a temporary exit sign will be installed on 3/29/2023 above the boundary doors going east to indicate the path of egress from the suite. Changes are being made on the code footprint to reflect the suite boundary modifications and exit sign...The fire watch will be extended into the vestibule until the above outlined corrections are completed..." The surveyor validated the plan of removal on 03/29/23 and notified the hospital that the IJ was removed at 2:30 PM prior to the survey exit.

Refer to the LSC findings (ASPEN #NTZC21; K-252) dated 03/29/23 for further details.

Based on observation and staff interview, the Hospital failed to ensure the occupants in the Emergency Room were provided with two, clearly identified, exits from the Trauma Bay suite as required per 2012 National Fire Protection Agency 101, Life Safety Code, 18.2.5.4.

This deficient practice affects all staff and up to 6 patients, who could become isolated in the Trauma Bay and could not exit the building safely during an emergency likely resulting in serious injury, serious harm, serious impairment, or death.

Findings Include:

Observation during the Life Safety Code (LSC) complaint investigation survey on 3/28/23 at 11:05 AM revealed the following: there is only one exit from the Trauma Bay in the Emergency Room Suite. The Emergency Room suite normally provides two exits from the interior, however, it had been modified during a current construction project. This resulted in the Trauma Bay exiting into a corridor which does not provide two clearly identified exits once outside the suite.

Staff A, Manager Regulatory Readiness and Staff B, Maintenance Director were present during the survey and acknowledged the findings.

Refer to the Life Safety Code findings (ASPEN #NZCT21) dated 03/29/22 for further details.

Number of Exits - Corridors
Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies.
18.2.5.4, 19.2.5.4