Corridor Door Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain corridor doors in compliance with NFPA 101 standards, as observed during a survey on December 17, 2024. Specifically, the door to room #3430 did not latch properly when tested, which is a requirement for doors protecting corridor openings to resist the passage of smoke. This deficiency was noted at 10:17 a.m. and indicates a failure in ensuring that the door hardware functions correctly to provide the necessary fire protection. Additionally, several doors throughout the facility were found to have decorations covering more than 50% of the door surface. This observation was made at 10:30 a.m. and violates the standards for corridor doors, which must remain free of obstructions that could impede their function in resisting smoke passage. These findings were confirmed in an interview with the Unit Director of TCU, Facility Staff, and the Safety Manager later that day.
Plan Of Correction
The door to room 3430 will be repaired to close and latch. The door decorations will be removed. This will be reported to the hospital safety committee and included in the hospital quality assurance program. Door maintenance and functionality is monitored and will continue to be monitored during hazard surveillance rounds by a multi-disciplinary team including representatives from safety, infection control, facilities, and environmental services.