HospitalInspections.org

Based on observation and interview, this facility did not assure all staff in the facility have a way to unlock the required exit doors within the means of egress, to allow access to a public way (a street or similar area open to the outside air and dedicated to public use) in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.2.2.2.5.1 and 19.2.2.2.6. This deficient practice affects all occupants including residents, staff, and visitors within 1 of 3 locked psychiatric units (the Adult Psychiatric West Patient Unit). The unit had a capacity of 15 patients and a census of 13 patients at the time of the self report.

The facility staff's inability to access the locked psychiatric unit, during a fire emergency, along with the staff's inability to remove the patients during a fire, resulted in an Immediate Jeopardy situation (a crisis situation where the staff's non-compliance placed the patients at a serious liklihood for death or serious injury from a fire. The state agency surveyors notified the hospital's administrative staff of the Immediate Jeopardy situation on 8/2/2024. The hospital's administrative staff removed the immedicay by placing a staff member with the appropriate keys outside the locked doors to allow staff entry/egress through the locked doors. The survey team verified the implementation of the plan to remove the immedicay prior to leaving. Upon survey staff leaving on 08/02/24 the deficiency remained, leaving the deficient practice at no actual harm level with the potential for more than minimal harm that is not Immediate Jeopardy that would affect all occupants.


Findings include:

1. Observation and interview on 7/11/2024, at 1:57 p.m., the Joint Emergency Communications Center received a 911 call from the University Hospital ( UIHC) stating there was a cell phone fire inside patient room 2781, in the locked Psychiatric Unit within the Pappajohn Pavilion. UI Police and the Iowa City, North Liberty, and Coralville Fire Departments were dispatched to the building. Staff Member A was directed by Staff Member B to the Adult Psychiatric West Patient Unit. Staff Member B attempted to badge into the unit via the main front doors but was denied access. Staff Member B attempted to by-pass the prox. reader by a key switch, which also did not allow access. Staff then, using a key, got Staff Member A through the unit's interior corridor, where nursing staff had relocated the patients to. The staff were instructed to move the patients further away from the incident scene. Upon arriving to Room 2781, the main corridor was filled with light smoke and residue of dry chemical fire extinguisher use. A well burnt cell phone was on the floor in the room, surrounded by a large puddle of water and dry chemical residue. The Iowa City Fire Department arrived on scene and between them, UIHC security and maintenance staff, they began mechanical smoke removal from the scene. The unit was "evacuated" for a period of 2 hours until the environment was fully clear and approved for re-occupancy by UIHC Engineering and Environmental Services. The doors to this locked Psychiatric Unit did not release upon activation of the fire alarm system. Security and Engineering attempted to determine why the secured perimeter of the Adult Psychiatric Unit didn't release when it was acted on with keys. There may have been another door open in the perimeter which failed to release the door when it was acted on. DIAL Staff were notified of this event on 7/11/2024.

Upon testing of these doors on 8/2/24, it was determined the egress doors for this unit worked for emergency egress and ingress by both door key and emergency override key systems through the replication of smoke induced alarm activation which was the condition set that occurred on 7/11/2024 during the initial fire event. However, given the doors were unable to be opened on 7/11/2024 by the Staff present during the fire event, it was determined that the Staff had used the incorrect key attempting to egress out the doors which resulted in them unable to open the doors. Record review from 7/11/2024, revealed the facility did not meet the requirements for egress doors in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.2.2.2.5.1 and 19.2.2.2.6 which states "Provisions shall be made for the rapid removal of occupants by means of one of the following:

(a) Remote control of locks
(b) Keying of all locks to keys carried by staff at all times
(c) Other such reliable means available to the staff at all times"

It was determined on 8/2/24, that although the Staff have access to both keys and badges which satisfy sections (b) and (c) above respectively, they incorrectly used a key that did not operate these egress doors, resulting in them failing to meet the above sections on the day of the event.

The University of Iowa Hospital & Clinics Staff and Directors verified these finding at the time of the complaint survey.