Corridor Door Failed to Latch Due to Maintenance Issue
Penalty
Summary
During a facility tour and interview with the Maintenance Director, surveyors observed that the corridor door to Room 5 failed to latch when tested. The door was found to be rubbing against the door frame, which prevented it from properly securing. The Maintenance Director indicated that the issue was likely related to the door hinges and mentioned that staff usually checked on the doors. This deficiency affected 25 out of 46 residents in one of three smoke compartments. The report specifically notes that the corridor doors did not maintain the required latching function, as mandated by NFPA 101 and related regulations, which is necessary to resist the passage of smoke and fire. No additional details about the medical history or condition of the residents involved were provided in the report.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Maintenance staff on the same day after the first failed test addressed the issue with Rm. 5 door not latching by adjusting the hinges and striker plate, retested, and door successfully latched. 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 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: Rounds will be done monthly by maintenance and the proper setting of the doors will be logged and the administrator will review the rounds and develop a log. 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 Administrator shall report the outcome of the checks/inspections to the Quality Assurance and Assessment Committee (QA&A) during its monthly meeting. If determined that the facility has accomplished the objectives in the plan of correction as aforementioned and the results are successful, then the facility shall consider the matter resolved. The QA&A Committee shall continue to review until such time that the deficiency has been proven to be resolved for 3 consecutive months and/or as advised by the QA&A Committee. Date of Completion of Corrective Action: 05/19/2025