Obstructed Exits Due to Snow and Padlocks
Summary
Exits in Building #1 and Building #3 were not maintained in accordance with the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.10.1. Specifically, the G-wing and S-wing exit discharges were obstructed with snow and had padlocks on the gate doors, which impeded their full instant use. During observations, it was noted that the northwest and southwest exit discharges of the G-wing, as well as the four exit discharges from the S-wing, were blocked by snow. Additionally, the padlocks on the gate doors were not easily operable, as staff were not trained on how to open them. Interviews revealed that several maintenance staff were on sick leave, which contributed to the delay in clearing the snow from the exit discharge sidewalks. The Maintenance Supervisor indicated that the padlocks were designed to be twisted and broken off, but there was no documented evidence that staff were trained on this procedure. The G-wing charge nurse was unaware of how to open the padlock on the exit discharge gate door. The Administrator acknowledged the issue and mentioned plans to address the obstructions, but the report focuses on the existing deficiency and the lack of immediate action to ensure the exits were free of obstructions.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 1. The accumulated snow (measuring 0ö to 2ö) from the preceding weather event (ending 7 a.m.) was cleared by 3 p.m. This was the last section to be cleared following a full-day continuous effort. Exterior fence gate break-away padlocks were removed. 2. All other paths of egress, including all driveways, parking lots, etc. had been cleared as part of the full day response; identified areas were the last to be addressed but not overlooked. All other exterior fence gates were inspected and break-away locks removed where found. 3. All maintenance staff responsible for snow clearing will be made aware of the requirement to keep all areas of egress cleared of any obstruction; and to notify the Director of Plant Operations if additional resources are necessary during or following a snow event (when snow is the potential impediment). This information will be provided in written form by the Director of Plant Operations, with signature acknowledging receipt and understanding. Maintenance of egress routes will be included in new employee onboarding education. Fence gates will remain free of locking devices – alternative gate hardware requiring two hand function (non-locking) will be evaluated for potential installation. 4. Following any snow event for the next 3 months, egress paths will be visually inspected by the Director of Plant Operations (or as delegated) on no less than 2 hour intervals during and after the event to ensure paths are cleared in a timely manner. On a monthly basis for six months, an audit of all discharge exits will be inspected on a weekly basis to assure no obstructions exist. The results of this audit and the snow clearing audit will be reported to the Quality Assurance/Performance Improvement committee monthly. Responsible Party: Director of Plant Operations
Penalty
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