Delayed Egress Door Fails to Release During Emergency Exit Test
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 the door met the special locking arrangements for delayed egress as specified by regulations. Specifically, on May 6, 2025, at approximately 11:30 AM, it was found that the 300 unit delayed egress emergency exit door did not activate the delayed egress release process when pressure was applied to the door. This malfunction was directly observed and confirmed through an interview with the maintenance director at the time of the observation. This deficiency could affect up to 30 occupants in the event of an emergency evacuation, as the door's failure to release could prohibit or delay their exit. The report does not mention any specific residents or their medical conditions at the time of the deficiency, nor does it provide details about any immediate consequences resulting from the malfunction.
Plan Of Correction
Element 1: On May 16, 2025, maintenance staff installed highly visible signage ("Push to Exit" and "Emergency Exit Release") above and beside all magnetically locked egress doors. A staff member was assigned to test each door's emergency function to verify operability. Element 2: All residents were evaluated for reliance on egress doors for safe evacuation. No residents were affected by the magnetic locking system during the time of inspection. Element 3: All emergency exit devices were tested facility-wide for compliance. Staff training was conducted on May 16, 2025, to review emergency door operation, including the use of magnetic locks and identifying signage. Monthly egress drills will now include checks of all egress door systems, including magnetic locks. Element 4: The Maintenance Supervisor will conduct monthly tests of each egress door's emergency release function and verify signage placement and visibility. Audit results will be documented and reviewed in monthly Safety Committee meetings. Trends or failures will be escalated to QAPI for corrective planning. The administrator is responsible for the sustained compliance.