Failure to Maintain Hazardous Area Door Safety
Penalty
Summary
The facility failed to maintain the required safety standards for hazardous area doors, as evidenced by several observations. On October 8, 2024, it was observed that the basement Central Supply door lacked the necessary latching hardware and failed to positively latch. This deficiency was confirmed during an interview with the Director of Maintenance. Additionally, on October 28, 2024, the basement Laundry door was found unable to self-close due to a wedge placed in the door, which was also confirmed by the Director of Maintenance. Further observations on the same day revealed that the rated door to the basement Laundry Chute Room was impeded from closing by a wedge. This was again confirmed by the Director of Maintenance. Despite these findings, a follow-up observation on December 9, 2024, determined that the issue with the Central Supply door had not been corrected, as confirmed by the Director of Maintenance. These deficiencies indicate a failure to maintain the necessary fire safety measures in hazardous areas of the facility.
Plan Of Correction
1. Facility-wide audit of doors completed. Any doors found unable to positively latch were referred to the maintenance director and will be repaired or replaced as necessary. 2. Audits of door latches will be conducted monthly for 12 months. Random audit of no less than 3 doors will be conducted monthly thereafter. Results of the audits will be presented to our QAPI committee for review and analysis of need for ongoing monitoring. 3. Education will be provided to staff regarding not impeding doors from closing by Maint. Director. 4. Audits to ensure doors are not being impeded from closing will be conducted monthly for 12 months. Results of the audits will be presented to our QAPI committee for review and analysis of need for ongoing monitoring.