Hazardous Area Door Failed to Self-Close and Latch
Penalty
Summary
A deficiency was identified when the A Hall Resident Care Supply room door was observed not to self-close to a positive latch as required by Life Safety Code (LSC) 8.7.1.3. This observation was made during a facility inspection and confirmed in an interview with a maintenance staff member. The lack of a self-closing, positively latching door in this hazardous area means the area was not properly protected as required for spaces containing combustible or hazardous materials, as outlined in LSC 19.3.2.1. The deficiency was specifically noted in relation to the protection of hazardous areas, which is necessary to prevent the spread of fire and smoke within the facility.
Plan Of Correction
Element #1: A Hall Resident Care Supply room door self-closer has been adjusted. The A Hall Resident Care Supply room door was checked to ensure the door self-closed to a positive latch. Element #2: This deficient practice has the potential to affect 15 occupants of the facility in the event of a fire not being contained to the hazardous area. Hazardous area doors in the facility have been checked and verified that they self-close to a positive latch. Doors that did not self-close to a positive latch were fixed at the time of the audit. Element #3: Nursing Home Administrator/designee has completed re-education with the Environmental Service Director on the Fire and Smoke Doors policy by the completion date. Element #4: Environmental Services Director/designee will complete audits on hazardous area doors to ensure they self-close to a positive latch. Audits will be completed weekly for four weeks and then monthly thereafter until substantial compliance is sustained. Results of the audits will be reported to facility QAPI committee for review and recommendations. This plan of correction will be monitored at the routine Quality Assurance (QAPI) meeting until such a time it is identified by the committee that sustained substantial compliance has been achieved. The Nursing Home Administrator is responsible for attaining and maintaining compliance.