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Based on observation, review of facility documents and interview with staff, it was determined that the facility failed to ensure all staff are provided with a reliable means to unlock two of two exit stairwells in the event of an emergency (A0710).


Cross Reference:

482.41(b)(1)(2)(3) Life Safety From Fire

Based on observation, staff interview, and a review of facility documents, it was determined that the facility failed to ensure all staff are provided with a reliable means to unlock two of two exit stairwells in the event of an emergency.

Findings include:

Reference: National Fire Protection Association's Life Safety Code, 2012 Edition, 101:19.2.2.2.5.1 Door-locking arrangements shall be permitted where the clinical needs of patients require specialized protective measures or where patient pose a security threat, provided that staff can readily unlock doors at all times in accordance with 19.2.2.2.6.

Reference: National Fire Protection Association's Life Safety Code, 2012 Edition, 101:19.2.2.2.6. Doors that are located in the means of egress and are permitted to be locked under other provisions of 19.2.2.2.5 shall with all of the following: (1) Provisions shall be made for the rapid removal of occupants by one of the following means: (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. . . . "

During a tour of Inpatient Behavior Health Unit ROSA 2 on 2/5/24 at 10:30 AM, in the presence of Staff (S) 1, the Director of Quality, and S7, Senior Manager, two Exit Stairwell doors, which serve as the only exits from the inpatient unit, were held closed with magnetic locks. Upon interview, S7 stated that the key switch located adjacent to each stairwell door will release the magnetic hold device and allow egress in cases of fire.

Upon interview at 10:35 AM, when questioned if any staff carry the key while on the unit, S1 replied, "No." During the interview, S1 confirmed that the key is located in the medication dispensing machine behind the Nurse's Station. S1 also confirmed that only nurses can retreive the key from the machine.

During a review of the staff schedule for 2/5/24, in addition to Registered Nurses, approximately 11 staff members holding the following titles were working on the unit: Patient Care Technicians, Registered Social Workers, Clinical Specialist, Recreational Therapist, Mental Health Workers, and Environmental Services. S1 confirmed, these staff do not have access to the key to open the exit doors. These staff members would need to activate the fire alarm to release the doors.

At 11:43 AM, the Surveyor requested S4, a Registered Nurse, to access the exit door key from the medication machine. S4 attempted twice but was unable to retrieve the key. The medication dispensing machine screen indicated, "Out of Stock."

At 11:48 AM, S2, the Assistant Nurse Manager, attempted to retrieve the exit door key from the medication machine. S2 was unable to access the key. S2 stated, "we should get Pharmacy up here to fix this." After several attempts, S2 was able to access the key. S2 pulled out a key ring with approximately 15 keys. After approximately 10 seconds, S2 was able to find the key labeled, "FD" for Fire Door.

S1 confirmed the above finding.