Delayed Egress Lock Failure
Penalty
Summary
The facility failed to meet the delayed egress locking requirements as specified in the NFPA 101 Life Safety Code (2012 Edition). During an observation, it was noted that an exit door between rooms 101 and 118 did not sound an audible alarm after 15 seconds of pressure was applied, as required. The signage on the door indicated that the locks would unlock after 15 seconds and an alarm would sound, but this did not occur. This deficiency had the potential to affect staff and 12 residents. During an interview conducted at the time of the observation, a staff member confirmed the finding and stated that the facility was unaware that the delayed egress lock was not functioning properly.
Plan Of Correction
The delayed egress door for exit between rooms 101 and 118 was repaired to initiate an audible alarm after 15 seconds of pressure is applied to the door. All residents have the potential to be affected by this deficient practice. The Maintenance Director checked all delayed egress doors in the building to assure all had audible alarm after 15 seconds of pressure is applied to the door. All doors were found to be in working order. The Maintenance Director will make monthly rounds to ensure all delayed egress door initiates an audible alarm after 15 seconds of pressure is applied to the door. The Maintenance Director will report the results of these audits to the Administrator on a monthly basis. The Maintenance Director will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters.