Improper Egress Door Locking Mechanism in Kitchen Storage
Penalty
Summary
Surveyors observed that the facility failed to ensure that doors in a required means of egress were not equipped with a latch or lock requiring the use of a tool or key from the egress side, unless compliant with special locking arrangements for clinical needs. Specifically, during an inspection, it was found that the cooler door for kitchen storage was equipped with a hasp latching mechanism and a padlock, which could allow the door to be locked from the outside. This hardware arrangement created a situation where someone inside the cooler could be locked in without a means to exit, as the locking mechanism did not meet the required standards for egress doors. The finding was confirmed through an interview with Facility Maintenance at the time of observation. The deficiency was noted to potentially affect 15 occupants in the event of an egress emergency.
Plan Of Correction
Maintenance Director adjusted the cooler door in the kitchen to ensure proper functioning. All other doors were checked and corrected as identified. The Maintenance Director was educated on K222 tag to ensure proper means of egress in the event of an emergency. Maintenance Director will complete facility rounds to ensure concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. Administrator is responsible for maintaining compliance.