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INTERMOUNTAIN HEALTH CASSIA REGIONAL HOSPITAL
No Description Available
Tag No.: K0038
Based upon observation, interview and operational testing the facility failed to ensure immediate access to exit discharge. Failure to provide immediate and direct access to exits can cause panic and injuries or death.
Findings include:
During the facility tour on June 19, 2012 between 1:30 PM and 5:00 PM observation revealed electro-magnetic locks used to secure three (3) direct exit doors at the mother baby unit; med/surg unit, and the critical care unit without a clear clinical need to lock these doors. The doors were secured from exiting without a staff only magnetic swipe card. Operational testing indicated that without staff assistance, the door would not release upon attempting to exit. Operational testing on June 20, 2012 at 9:45 AM revealed the door mechanism did release upon activation of the fire alarm.
Interview with the Director of Safety, Security and Environmental Health, indicated that the facility believed the security of infants over rode the need to maintain immediate access, and therefore the staff control of these locking devices was allowed. This deficient practice affected all patients, staff and visitors present on the dates of the survey. The facility is licensed for 25 beds and had a census of 24 on June 19, 2012.
Actual NFPA standard:
19.2.2.2.4
Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5.)
Exception No. 2*: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.