Obstructed Egress and Locked Exit Gate
Penalty
Summary
The facility failed to maintain clear and unobstructed means of egress as required by the 2012 NFPA 101 standards. During a life safety survey, it was observed that the first-floor corridor near the morgue was obstructed by combustible items, including wheelchairs and a floor polishing machine, stored next to the door leading to an adjacent corridor. Additionally, in the first-floor corridor behind the kitchen, numerous boxes were stored on either side, reducing the corridor's width to less than the required 48 inches. These obstructions were noted during the survey and were stated by the facility to be temporary, yet they persisted over multiple observations. Furthermore, the discharge from stair B, which leads to a sprinklered parking structure and then out to a gate leading to the public way, was found to be locked. A means to open this gate was not made available to all staff, further impeding the egress route. These deficiencies were acknowledged by the Director of Maintenance at the time of the survey, indicating a lapse in maintaining the required safety standards for egress in the facility.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 K 211. Immediate Corrective Action: The maintenance and housekeeping director immediately removed the wheelchairs, floor polishing machines, and other obstructive items stored near egress routes. All boxes observed in the corridor were removed. Metro Fire Alarm system and Technology tied the garage gate to the fire alarm system on (MONTH) 6, 2025; the gate now opens when the Fire alarm is activated. Element 2: All residents have the potential to be affected by this practice. The maintenance and housekeeping director immediately audited all hallways within the building to ensure means of egress were not blocked, and no other issues were identified. Element 3: The fire alarm system's policy and procedure were reviewed, and the installation of an automatic parking lot gate opening will be added to the policy. All staff will be in-serviced for this new procedure. Maintenance and security will be trained to ensure that the gate is opened due to fire alarm activation and that it immediately closes when the alarm has been cleared. Element 4: The maintenance and housekeeping director will audit all corridors weekly to ensure they are free of impediments to egress and maintained at 48 in width. Results will be reported to the administrator monthly. On a monthly basis for three quarters, the maintenance and housekeeping director will report findings to the QAPI Committee for review. QAPI Committee to determine if further action is required. Element 5: Persons responsible: Maintenance and housekeeping director.