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Based on observations, review of the facility construction documents and interviews with facility staff, the facility failed to maintain safe and reliable means of emergency exit and fire protection for the Women's Center Delivery Suite. Failure to maintain exits and exit access is likely to result in patient, visitors and staff becoming confused or unable to exit in a timely manner in an emergency. Obstructed sprinklers could result in inadequate fire protection in the event of a fire.

At the hospital's staff request, on or about 3/25/14, the construction contractor built a temporary wall at the Women's Center Delivery Suite. The temporary wall blocked exits and prevented the passage of a bedridden patient. Exit signs were covered. The temporary wall obstructed sprinkler coverage in the event of a fire. The effect of this construction resulted in an Immediate Jeopardy for the hospital's failure to ensure the safety of patients, visitors and staff for a 6 week period (refer to A-710).

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Based on observations, review of the construction documents and staff interviews; the facility failed to maintain a safe and reliable means of emergency exit and fire control. Failure to maintain exits and exit access put building occupants at risk of becoming confused or unable to exit in a timely manner in an emergency. The obstruction of the sprinklers could delay or deny extinguishment of a fire. These conditions pose an Immediate Jeopardy situation. Some 138 patients received maternity services, under these conditions during the 6 weeks the temporary wall was in place.

Findings include:

On 4/25/14 at about 10:45 a.m., while on tour of the facility with the Facility Maintenance Director, the Safety Director and the Nurse Manager of the Women's Center Delivery Suite; the surveyor made the following observations:

1) A remodeling construction project was in progress at the time of the survey. A temporary wall was constructed at the nurses' station between the delivery suite and the inpatient treatment area. The wall had a door with a locking device at the delivery suite side of the door. The wall extended within 17" of the ceiling. The wall and door were constructed at an angle that would prevent the passage of a bedridden patient on a stretcher. No exit sign was visible at the wall and door. An exit sign leading to an exit was visible at the opposite side of the door.

In interviews on 4/25/14, facility staff indicated that the wall and door were constructed as a security measure for the labor and delivery areas.
In an interview on 4/25/14, the Maintenance Director and the Safety Director stated they "did not know the wall had been constructed."

In an interview on 4/25/14 at 11:48 a.m., the Nurse Manager reported there have been 138 patients in the labor and delivery area over the past 6 weeks.
The Nurse Manager stated that the wall had been constructed as "a security measure", and "it had been in place for approximately 6 weeks."

The blocking of the exit door violates the recognized National Fire Protection Association (NFPA) standards for fire safety. According to NFPA 101, the Life Safety Code (2000 edition), Chapter 7 - Means of Egress:
7.5.1.2, "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel. Exit access corridors shall provide access to not less than two approved exits without passing through any intervening rooms other than corridors, lobbies and other spaces permitted to be open to the corridor."
7.5.2.2 "Exit access and exit doors shall be designed and arranged to be clearly recognizable. Hangings or draperies shall not be placed over exit doors or located to conceal or obscure any exit. Mirrors shall not be placed on exit doors. Mirrors shall not be placed in or adjacent to any exit in such a manner as to confuse the direction of exit."

2) The corridor leading from the delivery suite to the south west exit had an exit sign that was covered with a piece of cardboard. The doors at the end of the corridor had the vision panels covered with construction paper. The doors led into a vestibule which was being used as a construction office and for storage of construction tools and materials.
In an interview on 4/25/14, the Construction Project Manager confirmed this.
Covering signage violates the recognized National Fire Protection Association (NFPA) standards for fire safety. According to NFPA 101, the Life Safety Code (2000 edition), Chapter 7 - Means of Egress:
7.10.1.4 "Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs."
7.10.1.7 "Every sign required in Section 7.10 shall be located and of such size, distinctive color and design that it is readily visible and shall provide contrast with decorations, interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted."

3) There was an exit sign at the entrance into the delivery suite. The exit sign indicated travel down the third corridor (patient rooms 1-4). The direction of travel was neither visible at the delivery suite exit nor at the opposite end of the corridor. Review of the facility construction documents indicated the directional indicator was intended to lead occupants to the exit that was being used as a construction office.

Inadequate signage violates the recognized National Fire Protection Association (NFPA) standards for fire safety. According to NFPA 101, the Life Safety Code (2000 edition), Chapter 7 - Means of Egress:
7.10.2 "A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.", and 19.2.4.1; "Not less than two exits of the types described in 19.2.2.2 through 19.2.2.10, remotely located from each other, shall be provided for each floor or fire section of the building.", and 19.2.5.2; "Any patient sleeping room, or any suite that includes patient sleeping rooms, of more than 1000 ft2 (93 m2) shall have not less than two exit access doors remotely located from each other."

4) The temporary wall constructed at the nurse's station between the delivery suite and the inpatient treatment area extended to within 15" of the deflector of a pendant sprinkler head. This would obstruct the spray pattern of the sprinkler. In the event of fire could delay or deny extinguishment of a fire.

Obstructing the sprinkler pattern violates the recognized National Fire Protection Association (NFPA) standards for sprinkler systems. According to NFPA 13, Standards for Sprinkler Systems (1999 edition), Chapter 5 - Occupancy:
5-5.5.2.1 "Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 5-5.5.2." and
5-5.5.3 "Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 5-5.5.3."

5) In an interview on 4/25/14, the Construction Manager stated, "The wall and door had been constructed at the request of the Women's Center management staff to enable construction traffic to be allowed while providing for the security of the unit."

Review of both the facility construction documents and the documents for the remodeling of the neo-natal intensive care (NICU) and nursery did not indicate the wall and door as part of the facility plan or the construction project that was in progress at the time of the survey.
Review of the facility's Interim Life Safety Measures (ILSM) did not indicate any reduction of exit access in this area.

Building permitting, plan review, and construction are requirements of the Florida Administrative Code 59A-3.080 Plans Submission and Fee Requirements. The code requires:
(1) "No construction work, including demolition, shall be started until prior written approval has been given by the Office of Plans and Construction. This includes all construction of new facilities and any and all additions, modifications or renovations to existing facilities..." and
(9)(a) 4.c. "If the project is an addition, alteration or conversion of an existing building, fully developed life safety plans shall be submitted."
The required plan review would have revealed the fire safety hazards.

5) On 4/25/14 at 10:50 a.m., after surveyor intervention and upon notification of an immediate jeopardy situation, the facility's Safety Director began a fire watch in the area. The facility staff notified North Naples Fire Rescue of the situation. The construction contractor initiated the removal of the temporary wall, door and restored exit corridors, exit signage and sprinkler coverage to pre-construction conditions. This was completed on 4/25/14 by 12:45 p.m. These actions effectively removed the Immediate Jeopardy.