Failure to Provide Complete Smoke Compartmentalization
Penalty
Summary
The facility failed to ensure that smoke barriers were provided to form at least two smoke compartments on every floor as required by applicable codes. During a record review, it was found that the facility did not provide a smoke barrier map that demonstrated complete compartmentalization by smoke barriers throughout the building. The map provided did not show smoke barriers separating smoke compartments from outside wall to outside wall in each compartment, as required. This finding was confirmed during an interview with Facility Maintenance at the time of the record review. No information about specific patients, their medical history, or their condition at the time of the deficiency was included in the report.
Plan Of Correction
K 371 Facility floor plan was reviewed and revised to include smoke compartments. Floor plans in the facility will be replaced to meet requirements. Maintenance Director was educated on K371 tag that floor plan must identify smoke barrier walls. Maintenance Director will review floor plans with any changes to ensure compliance with updates. 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.