Corridor Doors Blocked by PPE Hangers Preventing Smoke Resistance
Penalty
Summary
The facility failed to ensure that corridor doors protecting corridor openings were able to resist the passage of smoke as required by NFPA 19.3.6.3. During observations, it was found that several resident room doors, specifically room #3 in cottonwood hall and rooms #44 and #4 in maple hall, did not close and positively latch. The deficiency was directly caused by personal protective equipment (PPE) hangers that were mounted on the top of these doors, which physically prevented the doors from closing and latching as required. These findings were confirmed during interviews with the facility Maintenance Director at the time of observation. The report notes that this issue could potentially affect 24 occupants within the smoke compartment if the doors fail to prevent the passage of smoke during a fire. The deficiency was identified through direct observation and interview, with no mention of corrective actions or follow-up steps included in the report.
Plan Of Correction
Maintenance removed all over the door hangers and mounted PPE holders with a different method so as not to impede door from having a positive latch. All other doors have been inspected to ensure that no obstructions keep the doors from latching. The maintenance staff will check doors weekly and document checks in the preventative maintenance log. The Maintenance Director will monitor compliance by conducting rounds weekly, observing for door latching issues.