Corridor Door Obstructions and Maintenance Issues
Summary
During a Life Safety Survey, it was observed that corridor doors in a long-term care facility were not properly maintained, leading to obstructions and failure to latch into their frames. On Unit 6, a folding walker and a trash receptacle were found obstructing the doors to Resident Rooms 631 and 633, respectively. On Unit 5, a plastic door chock was wedged under the door of Resident Room 519, and a chair was placed against the door of Resident Room 532, preventing them from closing. Additionally, a three-foot-tall circular floor fan was obstructing the Server room door in the Basement A Wing, which was left open due to a broken air conditioning unit. The Maintenance Director confirmed the fan was used to cool the equipment in the room. Further observations revealed that the corridor door of the Employee Break room in the Basement did not latch due to being hung up on its frame. The Maintenance Director mentioned that a request for an angle grinder to fix the metal door had not been approved. On Unit 6, three-drawer precautions cabinets were found obstructing the doors to Resident Rooms 610 and 617, and a similar cabinet was found against the door of Resident Room 526 on Unit 5. The facility's Annual Door Audit sheets indicated that the corridor doors had been checked in September 2024, but these issues persisted, affecting the safety and functionality of the doors.
Plan Of Correction
Plan of Correction: Approved January 2, 2025 1. 1st Floor - Unit 6 - Folding walker against corridor door to Resident Room 631 obstructing the door from closing was removed during survey. 1st Floor - Unit 6 - Trash receptacle against corridor door of Resident Room 633 obstructing the door from closing was removed during survey. 1st Floor - Unit 5 - Plastic Chock wedged under the corridor door of Resident Room 519 obstructing the door from closing. When chock removed, the door did not self-close or latch into its door frame. The door was repaired by Maintenance Director. 1st Floor - Unit 5 chair against the corridor door of Resident Room 532 obstructing the door from closing was removed during survey. Basement - A Wing - Floor Fan against Server Room Corridor door (A5) obstructing the door from closing was removed during survey. Basement - corridor door (B6) of the Employee Break room did not latch into its doorframe. The door was repaired by Maintenance Director. 1st Floor - Unit 6 - precaution cabinet stored in front and against the corridor door of Resident Room 610 obstructing the door from closing was removed during survey. 1st Floor - Unit 6 - precaution cabinet stored in front and against the corridor door of Resident Room 617 obstructing the door from closing was removed during survey. 1st Floor - Unit 5 - precaution cabinet stored in front and against the corridor door of Resident Room 526 obstructing the door from closing was removed during survey. 2. All Residents are at risk for deficient practice of obstructed doors and doors not closing and latching in their frames. 3. A 100% audit of all Units/corridor doors was conducted on 12/26/2024 to ensure that all doors are unobstructed. Any deficient findings were corrected immediately. 4. A 100% audit of all doors/latches and doorframes was conducted on 12/26/2024 to identify any doors not properly functioning. Any deficient findings were corrected immediately. 5. Administrator reviewed policy and procedure on corridor doors. No changes were made to the policy. Administrator educated Maintenance Director and Maintenance Tech on the policy and procedure of obstructed doors and doors latching properly. 6. All staff will be in-serviced with a post-test for competency by the Consultant regarding properly functioning doors, notification to maintenance regarding improperly functioning doors, and deficient practice of obstructing doors. 7. The Director of Maintenance will conduct a monthly survey of all corridor doors and report findings to the QAPI Monthly Meeting. Person Responsible: Maintenance Director
Penalty
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