Plan for Access Control for SFMC 3rd Floor: SFMC
October 12, 2010
Attendees: Nate Olson, Margaret Gilbert, Rebecca Kahl, Mark Hartman, David Howard
Background: Final interpretation of fire code related to the areas of concern rendered by Sean Donohue of RJA on August 9, 2010. Their interpretation concludes that we cannot lock the double doors leading from the staff elevators into the birth center as this creates a “dead-end corridor”.
Decision of this group for controlling access onto the mother/baby unit:Both sets of doors onto this unit will remain closed, not locked. For the staff elevator side doors, we will place an overhead sign past the entrance to triage stating, “Staff Only, Do Not Enter”. We will place a sign overhead or directly on the double doors off the staff elevators stating, “Do Not Enter, Staff Only”.
For the main doors onto the unit we will continue with current signage (see attached). All visitors entering the unit must identify who they are and who they are here to visit. Staff at the desk will verify that visitors are not on the “Do Not Visit” list. Approved visitors will be issued a visible badge. Visitors will be encouraged to return their badge when exiting the unit. All visitors on the mother/baby unit must have a visitor badge (except for the father who will have a wristband). All staff on the unit will assist in controlling access by verifying that all visitors to the unit have either a staff badge or a visitor badge. We will change the color of badges monthly.
Decision of this group for controlling access onto the pediatrics unit:A set of double doors will be placed at the back entrance onto the unit (coming from the NICU). These doors will be kept closed and locked. Access will be available to staff only via badge reader.
A set of double doors will also be placed at the main entrance to the pediatric unit, between the lactation retail store and the staff break room. These doors also will be kept closed but not locked. They will have windows but with limited visibility. Visitors will be made aware of the need to obtain a visitor’s badge at the nurses’ station when entering the unit. The message will be communicated via signage on the doors (see attached) as well as by volunteer staff at the desk outside of the pediatric unit. The badge must be worn at all times by visitors to the pediatric unit. Visitors from the NICU traveling to the Ronald McDonald room will be issued a badge by the NICU staff which will allow them entrance onto the pediatric unit. They will be encouraged to utilize the main entry doors onto the unit. All staff on the unit will assist in controlling access by verifying that all visitors to the unit have either a staff badge or a visitor badge. We will change the color of badges monthly.
Additional security measures are as follows:
Nursing will continue to utilize the policy of not placing patients in the rooms closest to the staff break room.
A chime will continue to provide an auditory alert to staff of people entering their unit.
Security will initiate a plan for hourly rounding through the pediatric unit from 1900 to 0700.