Corridor Door Failed to Latch and Resist Smoke Passage
Penalty
Summary
During an inspection, it was observed that the corridor room door at resident room #20 did not close to a positive latch as required by Life Safety Code (LSC) 19.3.6.3.5. The door failed to meet the standard for resisting the passage of smoke, which is necessary for corridor doors in areas other than required enclosures of vertical openings, exits, or hazardous areas. The deficiency was identified through direct observation and confirmed in an interview with a maintenance staff member at the time of the inspection. The report specifies that the door in question did not provide the required positive latching hardware, which is essential for ensuring the door remains closed and can resist smoke passage. This failure was noted as a violation of the applicable regulations and could potentially affect 15 occupants in the event of a fire not being contained to the smoke compartment. No additional details about the medical history or condition of the residents in the affected room were provided in the report.
Plan Of Correction
The Nursing Home Administrator is responsible for attaining and maintaining compliance. Element #1: The corridor room door at resident room #20 has been repaired. Resident room #20 door has been checked to ensure the door closed to a positive latch. Element #2: This deficient practice could potentially affect 15 occupants of the facility in the event of a fire not being contained to the smoke compartment. Resident room doors in the facility have been checked and verified that they close to a positive latch. Any doors that did not 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 Services Director on the Fire and Smoke Doors policy to a positive latch by the completion date. Element #4: Environmental Services Director/designee will audit to ensure resident room doors close to a positive latch. Audits will be completed for 10 random resident rooms weekly for four weeks and then monthly thereafter until substantial compliance has been 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.