Improper Storage in Exit Passageways
Summary
During a recertification survey, it was observed that the exit passageways in a facility were not maintained according to the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.3.2.3. Specifically, the exit passageway from the kitchen storeroom was used as storage space for plastic bins designated for confidential shredding, two 33-gallon containers for soiled mop heads and cloth rags, and empty milk crates. Additionally, the employee entrance exit passageway was used to store equipment. These observations were made on December 17, 2024, at 2:10 PM. During an interview conducted at 2:59 PM on the same day, an administrator acknowledged the issue and stated that they would prioritize keeping the exit passageways clear.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) All items were removed from both exit passageways on 12/17/2024. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. The administrator completed rounds of the facility to ensure all exit passageways were maintained free of obstructions. No other areas were identified. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) The maintenance director and food service director were educated by the administrator on maintaining exit passageways via a physical tour of the areas. Education was given on maintaining exit passageways clear and to use the newly designated alternate storage areas. The maintenance director or administrator will complete a weekly audit of the kitchen storeroom exit and employee entrance exit to ensure the passageways are free of any stored items or equipment blocking the passageway. Any noncompliance will be corrected upon identification. The audit will be completed weekly for 8 weeks and monthly for 2 months thereafter. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) The facility will ensure that the exit passageways are kept clear at all times via the weekly environmental rounding schedule with any violations immediately addressed. Findings of the weekly and monthly audits will be reviewed by the Quality Assurance Performance Improvement Committee monthly, and additional recommendations for interventions and duration of audits will be given as needed. Responsible Party: Director of Maintenance
Penalty
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