Corridor Doors Obstructed by Staff Items
Penalty
Summary
During a facility tour, surveyors observed that corridor doors intended to protect openings were obstructed, preventing them from closing as required by NFPA 101 Life Safety Code. Specifically, the corridor door of Room 226 was blocked by a trash can, and the corridor door of Room 221 was obstructed by a plastic bag full of clothes. These obstructions resulted in both doors being unable to close properly. The Maintenance Director confirmed during interviews that staff had placed these items in front of the doors, with the intention of moving them later. These findings affected one of two smoke compartments in the facility and impacted 22 of 45 residents. The report does not provide additional details about the medical history or condition of the residents involved at the time of the deficiency.
Plan Of Correction
Immediate Correction: The items blocking the doors were removed. All residents have the potential to be impacted by the finding, but no harm was identified and no other doors were found blocked upon inspection. Sustainment: Education was provided to the SCU staff by the Director of Staff Development on the requirement that all fire doors remain clear and able to close properly in order to protect life and property in case of fire. See attached sign-in sheets. Monitoring: Rounding will occur three times a week by the Manager of the Special Care Department to verify that no doors are blocked or obstructed in any way. Data will be collected and reported out to the SCU Quality Assurance Committee as part of the facility's QAPI program. Person Responsible: SCU Nurse Manager