Non-compliant Egress Door Locks
Penalty
Summary
During a Life Safety Code survey, it was observed that certain facility doors were not maintained in compliance with safety regulations. Specifically, doors within a means of egress were equipped with locks that required more than one releasing operation to open. On the first floor, the door separating the Unit 1/2 Resident Lounge from the Unit 1 corridor had a thumb turn lock that required two actions to open: turning the thumb lock to the unlocked position and then turning the doorknob. The Maintenance Director confirmed that the maintenance staff had inspected the facility's corridor doors and had documentation for these inspections. Further observations in the basement revealed similar issues with doors leading to storage rooms. The door to the La(NAME) storage room and the Therapy Storage room (A5) both had thumb turn locks requiring two actions to open. These doors were also marked with illuminated exit signs. The facility's Annual Door Audit sheets indicated that the doors were checked in September 2024, but the deficiency persisted, affecting the safety of the egress routes.
Plan Of Correction
Plan of Correction: Approved December 31, 2024 1. All locks requiring more than one releasing operation were audited on 12/30/2024 by Maintenance Director. The door that separates the first and second unit was audited and the locking mechanism was replaced. The door in the basement by La(NAME) Storage room was audited by the Maintenance Director on 12/30/2024 and the locking mechanism was replaced. The door for therapy storage in the basement was audited by the Maintenance Director on 12/30/2024 and the locking mechanism was replaced. 2. All residents are at risk for deficient practice of doors within a means of egress being equipped with locking mechanisms with more than one releasing mechanism. 3. The policy and procedure for life safety doors with a section on doors within a means of egress was created on 12/30/2024 by the Administrator. 4. An entire building-wide audit will be conducted on all doors within a means of egress having locks with more than one releasing mechanism. All doors with deficient practice will be repaired. 5. The Maintenance Director/Tech will be educated on this issue by the Administrator on 1/10/2025. 6. The Maintenance Director will report completion of lock changes to the QAPI Committee to ensure compliance with K200. An audit will be completed monthly by the Maintenance Director/Tech to ensure this issue is no longer present in the facility. The QAPI Committee will review completion and determine any further changes needed. Person Responsible: Maintenance Director