Corridor Door Maintenance Deficiency
Penalty
Summary
During a Life Safety Code survey, it was observed that corridor doors in a long-term care facility were not properly maintained, affecting three of the four resident use floors. Specific issues included doors that did not latch into their frames and were obstructed from closing. On the second floor, the Treatment Room door required a forceful close, and the Janitor's Closet door was obstructed by a paper towel and a decoration hanger. On the first floor, the Respiratory Therapy Office door was propped open with a garbage can, despite being equipped with a magnetic hold-open device. In the basement, the Ladies Locker Room door did not latch, and on the second floor, the door to Resident Room 222 appeared warped. The facility's computerized maintenance system indicated that fire and smoke door inspections were not specific to door locations and were not conducted frequently enough to address the issues. The last annual inspection was completed nearly a year prior, and the monthly inspection did not specify door locations. Interviews revealed that an outside contractor had been hired to repair and replace certain doors, but there was no written list of the doors included in the project. Maintenance staff recalled that Resident Room 222's door was part of the project. During a post-survey revisit, it was found that the deficiency persisted, with the Ladies Locker Room door still not latching. Staff education on corridor doors was inconsistent, with some staff members reporting no recent education on the topic. The facility's Plan of Correction indicated that corrective actions were either completed or in progress, but the Maintenance Director, who was responsible for the plan's implementation, was on leave. The Administrator was unaware that some doors had not been repaired and assumed the contractor would complete the repairs before the plan's completion date.
Plan Of Correction
Plan of Correction: N/A Corrective action for the deficient corridor doors at the Unit 2 treatment room, unit 2 janitor’s closet, unit 1 respiratory therapy office, the ladies locker room, and resident room 222 is completed or in progress by outside contractor. Education will be provided to all staff related to corridor door operation and to the maintenance team on proper operation of corridor doors. A Monthly audit will be conducted for all corridor doors. The results of this audit will be logged monthly into the TELS system. The results of this audit will be reported to the QA committee on a monthly basis. Administrator will provide the education. Monitored Monthly for 3 months in QA. Responsible Designee: Maintenance Director