Failure to Maintain Positive Latching of Corridor Doors
Penalty
Summary
The facility failed to maintain the positive latching of corridor doors, specifically affecting the double doors to the Kitchen Dry Storage Room. During an observation on January 15, 2025, at 12:15 PM, it was noted that these doors did not automatically close in the required order, which resulted in their failure to latch within the frame. This issue was attributed to the malfunctioning of the associated door coordinator, which is essential for ensuring the doors close properly and maintain the necessary fire safety standards. An interview with the Facilities Director at the same time confirmed the observation, acknowledging that the doors failed to latch due to the door coordinator's failure. This deficiency impacts one of the eleven smoke compartments within the facility, highlighting a lapse in maintaining the required safety measures for corridor doors, which are crucial for preventing the passage of smoke and ensuring fire safety compliance.
Plan Of Correction
1. The Maintenance Director/designee will repair or replace the door coordinator on the double doors to the Kitchen Dry Storage Room to ensure proper closing and latching within the door frame. 2. The Maintenance Director and relevant staff members will receive training on NFPA 101 Standard - Corridor Doors, focusing on the importance of maintaining positive latching of corridor doors within smoke compartments. 3. The Maintenance Director/designee will inspect all corridor doors in the facility to verify proper latching within door frames. Special attention will be given to doors with coordinating devices. Monthly audits of corridor doors will be conducted to ensure continued compliance with positive latching requirements. Findings will be documented and reported for further action, if necessary. 4. Findings will be reviewed at the Quality Assurance Performance Improvement meeting.