Corridor Door Maintenance Deficiencies
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 multiple floors in both the front and rear buildings. On the second floor of the front building, the corridor door to the kitchenette failed to latch due to medical tape covering the strike plate, as noted by the Assistant Maintenance Director. Similarly, on the first floor of the rear building, the kitchenette door did not latch because medical tape was holding the latch inside the door, as explained by a registered nurse. Both instances were attributed to ongoing maintenance work involving the replacement of battery-powered keypad code locks. Further observations revealed additional issues with corridor doors. On the first floor of the rear building, the door to the Assistant Director of Nursing's office, equipped with a self-closer, was propped open by a large box, contrary to the Maintenance Director's statement that doors should not be held open. Additionally, on the first floor of the front building, the Janitor's Closet door next to the Kitchen did not latch due to a security plate obstruction, with the Assistant Maintenance Director unable to confirm when the plate was installed. It was also noted that there were no formal checks on corridor doors, and maintenance staff only addressed issues logged by staff.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 The medical tape on the corridor door to the kitchenette on the second floor of the front building was removed to allow the door to latch into its door frame. The medical tape on the corridor door to the kitchenette on the second floor of the rear building was removed to allow the door to latch into its door frame. The large box by the door to the Assistant Director of Nursing’s Office was removed to allow it to self-close and latch. The security plate on the corridor door to the janitor's closet next to the kitchen was adjusted to allow it to latch into its door frame. An audit was conducted of the facility's corridor doors to ensure doors latch into door frame and that they are not obstructed from closing. The Maintenance Director and maintenance staff were educated on the requirement to ensure corridor doors latch and corridor doors are not obstructed into its frame in accordance with NFPA 101. The Maintenance Director will conduct a monthly audit of all facility corridor doors. The audit will be monthly for 4 months. Results of the audits will be reviewed at QAPI. The Maintenance Director is responsible for the plan.