Failure to Maintain Delayed Egress Locking System
Penalty
Summary
The facility failed to maintain exit egress doors equipped with delayed egress locking arrangements as required by NFPA 101 standards. During an observation on November 14, 2024, it was noted that the exit door in the physical therapy suite did not release after 15 seconds of applying pressure against the crash bar, which is a violation of the delayed egress locking system requirements. This deficiency was confirmed during an exit interview with the Director of Nursing and the Maintenance Director. A follow-up onsite revisit conducted on January 8, 2025, revealed that the issue with the exit door had not been resolved. The door still did not release after 15 seconds of pressure against the crash bar, as confirmed in an interview with the Administrator and Maintenance Director. This indicates a continued failure to comply with the necessary safety standards for egress doors, posing potential risks to the safety of the facility's occupants.
Plan Of Correction
1. On 1/8/2025 Tilley fire was called for an update on the parts to repair the door. Service was scheduled for 1/10/2025 and door was repaired and back in working order. 2. To prevent reoccurrence a full house audit was conducted on 1/8/2025. 3. On 1/8/2025 NHA provided education to the Maintenance staff on the importance of checking all doors as required and repairing any issues timely. 4. Maintenance will audit weekly for 4 weeks. Then monthly for 3 months after. All trends are brought to QAPI for further action.