HospitalInspections.org

Bldg A1 (Anschutz Inpatient Pavilion)
Based on observation, record review and staff interview during the course of the survey, it was determined that the facility failed to maintain the separation between egress corridors and all other areas in accordance with Life Safety Code Section 19.3.6.1 and 19.3.6.2. This was evidenced by the following:

Egress corridors were not separated from patient treatment areas by non-fire rated smoke resistive partitions, as required. The Emergency Department Manager reported that the department utilized 21 "hall beds" for emergency patient care. The hall beds were used on a daily basis, depending upon patient census. Hall beds located within the emergency department core areas were utilized first with additional "disaster beds" (known as DSR beds #1through #10) utilized last. DSR beds #1 through #4 were located within the ambulance entry suite. DSR beds #5 through #10 were located in the Outpatient Pavilion Radiology egress corridor. A review of facility plans determined that the core area of the emergency department was arranged as three separate non-sleeping suites all within Bldg A1 (Anschutz Inpatient Pavilion) as follows:
South suite-ambulance entrance area- 2015 square feet.
Core area suite - 6289 square feet.
North area suite- 6167 square feet.
The plan review verified that 9 of the 21 hall beds were located within designated 8 ft. wide egress corridors and not within an internal suite passageway. The patient care beds, located within the designated egress corridors, were observed in the following locations:
Building A1: k/a Anschutz Inpatient Pavilion- 3 hall beds in the pharmacy egress corridor (1D0403).
Building 04: k/a Anschutz Outpatient Pavilion- 6 hall beds (DSR #5 through #10) in the Radiology egress corridor (1E0001 and 1G0001).
During a tour of the emergency department on October 9, 2012 at approximately 10:30 am, 11 of 21 hall beds were being utilized for emergency patient care. The beds in use included the 3 beds located in the pharmacy egress corridor. DSR beds #5 through #10 (located within the Radiology egress corridor) were not being utilized for patient care at the time of the emergency department tour.

The Life Safety Code Section 19.3.6.1 requires that corridors be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. Exception #1 to 19.3.6.1 allows some areas to be open to the egress corridor, however, the allowed areas exclude patient sleeping rooms, patient treatment rooms and hazardous areas. Section 19.3.6.2.2 requires that corridor walls separating use areas from the egress corridor form a barrier to limit the transfer of smoke.

Building 04: k/a Anschutz Outpatient Pavilion
Based on observation, it was determined that the facility failed to insure automatic smoke barrier door release in accordance with the Life Safety Code Section 19-2.2.2.6 and 7.2.1.8.2. This was evidenced by the following:

Cross-corridor smoke barrier doors were not maintained to automatically release and become self-closing, as required. One of two corridor smoke barrier doors (Outpatient Pavilion corridors 1E0001 and 1G0001) was observed to be obstructed by a wheelchair and mobile computer terminal. The stored equipment would prevent the doors from fully closing to form a smoke resistive barrier upon fire alarm initiated automatic release.

Life Safety Code Section 19.2.2.2.6 requires that doors be held open only by an automatic release device that complies with Section 7.2.1.8.2. The fire alarm system, automatic sprinkler system (if provided) and the systems required by Section 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Building 04: k/a Anschutz Outpatient Pavilion-
Based on observation during the survey, it was determined that the facility failed to maintain egress corridors that were clear and unobstructed in accordance with Life Safety Code Section 7.1.10 and 7.3.2. This was evidenced by the following:

Designated egress corridors were not continuously maintained free of obstructions and impediments to full instant use, as required. Egress corridors were observed to be obstructed in the following location:

The Outpatient Pavilion Radiology egress corridor (1E0001 and 1G0001) was obstructed by 6 patient care beds and associated equipment that included numerous 3 ft. wide wheeled cloth privacy screens, a metal chair, wheeled stool, wheelchair, mobile computer terminal, med cart, IV stand and a mobile bed table. The beds were not being utilized for patient care at the time of the facility tour. The stored beds and equipment reduced the corridor clearwidth to approximately 4 ft.

The Life Safety Code Section 7.1.10.1 requires that the means of egress be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.1.10.2.1 requires that no furnishings, decorations, or other objects obstruct exits, access thereto, egress therefrom, or visibility thereof.