Emergency Egress Door Required Multiple Actions to Unlock
Penalty
Summary
During a facility tour and interview with the Maintenance Director, surveyors observed that an emergency egress door near Room 1 was equipped with a door knob featuring a turn button lock. When tested, the door required two separate actions to unlock from the egress side. This configuration does not comply with NFPA 101 Life Safety Code requirements, which mandate that egress doors must be readily openable from the egress side without the use of a tool, key, or more than one action. The Maintenance Director confirmed during the interview that the door had been in this condition for some time. This deficiency affected 25 out of 46 residents located in one of the facility's three smoke compartments. The report does not mention any specific medical history or conditions of the residents involved at the time of the deficiency.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. The egress door near Room 1 was immediately repaired to eliminate the need for more than one action to open. A single-action, code-compliant push bar has been installed. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All residents have the potential to be affected by this deficient practice. No residents were found to be affected by this deficient practice. What measures will be put into place or what systemic changes in the facility will make to ensure that the deficient practice does not recur: All door hardware was checked, and visual checks will be part of the preventive maintenance schedule to inspect egress hardware monthly. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The log will be part of the facility QA program, and any deficient practices identified will have a QAPI developed to monitor and/or correct the deficient practice. Date of Completion of Corrective Action: 05/19/25 How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The log will be part of the facility QA program, and any deficient practices identified will have a QAPI developed to monitor and/or correct the deficient practice. Date of Completion of Corrective Action: 05/19/25 K 222