Delayed Egress Door Malfunction
Summary
During a Life Safety Code survey, a deficiency was identified involving a delayed egress door locking mechanism on the first floor of a facility. The mechanism, which is designed to release the door after 15 seconds when pressure is applied, failed to function as intended. This issue was observed during a test conducted by the Director of Plant Operations from a sister facility, who noted that the door did not open even after 30 seconds of pressure, despite the alarm sounding. The doors in question were located outside the Physical Therapy Gym and were equipped with signs indicating that they should open after 15 seconds of pressure. The facility's policy, titled Fire and Egress Door Inspection and Maintenance, mandates regular testing of delayed egress doors to ensure proper operation. According to the facility's log, the doors were tested weekly for alarm function and monthly for the 15-second release function, with the most recent tests conducted in December 2024 showing all doors as passing. However, during the survey, the door failed to operate as designed, and the Director of Plant Operations was unable to explain the malfunction. This deficiency affected one of the two resident use floors in the facility.
Plan Of Correction
Plan of Correction: Approved January 31, 2025 Corrective action for Affected Area: Physical Therapy gym doors were repaired on 1/6/25. Identification of other areas potentially affected: All residents have the potential to be affected by the same deficient practice. All of the facilities delayed egress door locking mechanisms were audited and are in working order. Steps to prevent further recurrence: Maintenance staff were reeducated on exit door delayed egress testing. Weekly testing of exit door alarms with delayed egress is occurring. How corrective action will be monitored: Director of Plant Operations will conduct monthly audits on each door to assure delayed egress doors are working properly. Results will be reported to the quality assurance committee. Director of Plant Operations will ensure compliance.
Penalty
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