Failure to Maintain Delayed-Egress Door Alarms and Locking Systems
Penalty
Summary
Surveyors observed that several emergency exit egress doors, specifically those leading to stairways on the 2nd and 3rd floors, were signed as having a 15-second delay with an alarm to sound upon opening. However, when these doors were tested, they opened freely without any resistance or alarm activation. This was confirmed during observations at multiple locations and times within the facility. The lack of functioning delayed-egress locking systems and alarms on these doors means that the doors did not operate as indicated by their signage. The facility failed to ensure that doors in a required means of egress were equipped and maintained in accordance with the special locking arrangements for clinical needs, as required by regulation. These findings were confirmed with the facility Maintenance Director at the time of observation.
Plan Of Correction
K222 Egress Doors 1. The facility failed to ensure doors in a required means of egress are not equipped with a latch or lock that requires the use of a tool or key from the egress unless meeting the special locking arrangements for clinical needs in accordance with 19.2.2.2.5.1 and 19.2.2.2.6. a. Emergency exit to egress door to Stairway "A" 3rd floor was assessed and serviced. b. Emergency exit egress door on 3rd floor by sitting was assessed and serviced. c. Emergency exit egress door to stairway "A" 2nd floor was assessed and serviced. 2. The maintenance director and staff will be educated on checking and maintaining any breaches in egress doors with a latch or lock throughout the facility. 3. To ensure continued compliance is maintained with the emergency fire exits, the Maintenance Director/designee will complete random audits 5x a week for 4 weeks. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.