Feb 24 2016

Strange Observations – Part 6

Category: BlogBKeyes @ 12:00 am
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Door with Conflicting SIgnage Web 2Continuing in a series of strange things that I have seen while consulting at hospitals….

This series of pictures is just plain sad… and wrong. The top picture shows a door in the path of egress with an ‘Exit’ sign over it. If you look closely, there is a magnetic lock on this door and there is a sign posted on the door as well. This door is in an exit access corridor and lead from one physician’s office area to another physician’s office area and for some reason was equipped with a magnetic lock. But the magnetic lock did not qualify for the exceptions to 19.2.2.2.4 of the 2000 LSC for delayed egress locks or access-control locks.

Take a look at the bottom picture… The picture is a close-up of the sign on the door. The sign says “This is not an exit…” but the ‘Exit’ sign over the door says “This is an exit”. That’s a conflict. To be sure, the door is an exit as this door was located in an exit access corridor and without the designated exit it would have been over a 100 foot dead-end corridor (which is not permitted). So, the exit is necessary.

But the conflicting signage is just wrong. Just because one physician’s office did not want people exiting into his area, you cannot lock the door and say the door is not an exit.

Close up of Door With Conflicting Signage Web 2I remember we tried to find out what actually releases the magnetic lock and the staff that I was with could not say. They said they were not sure if it released on a fire alarm and they checked with security and it did not release on any signal that security could transmit.

This is the type of deficiency that will lead to an Immediate Jeopardy decision and cause all sorts of headaches for a hospital.

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Feb 17 2016

Strange Observations – Part 5

Category: BlogBKeyes @ 12:00 am
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Blocked Exit Door Web 2Continuing in a series of strange things that I have seen while consulting at hospitals….

I don’t remember where in the hospital I took this picture but it is apparent that it is in a seldom used area. Someone felt it was okay to store tables and chairs in this area, and didn’t realize it was creating an obstruction to the exit doors. Or, even worse, they may have realized it and not cared that they are blocking access to the exit doors.

Whenever a surveyor finds access to an exit is obstructed, it can (and often does) lead to an adverse decision. Some accreditation organizations can consider this a condition level finding, which means the survey team returns within 45 days for a follow-up survey, and they notify CMS. And other accreditation organizations may even consider this an Immediate Jeopardy (IJ) issue that will get you another focus resurvey within 22 days and most likely a visit from CMS.

Don’t put yourself in a position whereby you are standing in the CEO’s office explaining why your lack of action lead to an adverse decision. Be pro-active and do frequent rounding looking for obvious problems.

 

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