Deficiency in Hazardous Area Door Maintenance
Penalty
Summary
The facility failed to maintain the required safety features for doors leading to hazardous areas, specifically affecting one of the three levels. During an observation on January 30, 2025, at 10:15 a.m., it was noted that the Infectious Waste Room within the ground floor Environmental Room was missing essential door hardware and a self-closing mechanism. This deficiency was confirmed during an exit interview with the Administrator and the Maintenance Director later that morning at 11:30 a.m.
Plan Of Correction
Step 1 Hardware and self-closer installed on the ground floor Infectious Waste Room. Step 2 A facility-wide audit was completed to ensure that all doors leading to a hazardous area had self-closer and the appropriate hardware installed. Step 3 The maintenance team was educated on the requirement to have the appropriate hardware and self-closer on doors leading to hazardous areas. Step 4 The maintenance director/ designee will audit the infectious waste room to ensure that appropriate hardware and self-closers are installed as required. Findings will be reviewed during QAPI.