Non-Functioning Internal Door Releases on Walk-In Refrigerator and Freezer
Penalty
Summary
Surveyors observed that the facility failed to maintain proper means of egress as required by NFPA 101, Life Safety Code. During a tour, it was found that both the walk-in refrigerator and freezer, located towards the back of the walk-in refrigerator, were equipped with deadbolt locks and internal release knobs intended to allow individuals to open the doors from the inside. However, when the Director of Maintenance (DOM) attempted to operate the internal release mechanisms from inside both units, the mechanisms failed to function. The deficiency was identified through direct observation and interview with the DOM, who stated he was unaware that the internal release knobs were not working. This issue was present in one of four smoke compartments within the facility. The report specifically notes that the non-functioning internal door release mechanisms could result in staff becoming trapped inside the walk-in units. No information was provided in the report regarding any residents being directly involved or affected at the time of the deficiency. The findings were limited to the staff's ability to exit the walk-in refrigerator and freezer in the event of an emergency, as observed during the facility tour.
Plan Of Correction
1. How corrective action will be accomplished for those residents found to have been affected by this deficient practice. The facility immediately addressed the non-functioning internal door release mechanism in the walk-in refrigerator and freezer doors. The doors were repaired to function properly so that no potential entrapment could occur. 2. How the facility will identify other residents having the potential to be affected. Staff who utilize the walk-in refrigerator and freezers have the potential to be affected. No residents have the potential to be affected. No other negative findings were noted. 3. What measures systems will be put into place to ensure the deficient practice does not recur. To ensure that the alleged deficient practice does not recur, the dietary staffs were in-serviced by the Environmental Service Director regarding "Means of Egress requirements." The Dietary Supervisor will monitor the walk-in refrigerator and freezer doors to make sure the locking mechanism is properly functioning so as not to impede egress weekly. Any negative findings will be corrected immediately and reported to the Administrator. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The Administrator will monitor monthly with members of the Safety Committee the weekly monitor in place for the walk-in refrigerator and freezer doors to make sure the locking mechanism is properly functioning so as not to impede egress. The findings will be reported to the QA/QAPI Committee at least quarterly for analysis, review, modification and/or correction. The utilization of portable fire extinguishers and their locations to hazardous areas. The Environmental Services Director and/or designee will verify monthly that the portable fire extinguishers within the building are in compliance and within the appropriate distance of hazardous areas. Any negative findings will be corrected immediately and reported to the Administrator. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The Administrator will monitor at least quarterly the monthly monitoring conducted by the Environmental Services Director that the portable fire extinguishers within the building comply and are within the appropriate distance of hazardous areas. The findings will be reported to the QA/QAPI Committee monthly for analysis, review, modification and/or correction. K711. 1. How corrective action will be accomplished for those residents found to have been affected by this deficient practice. The Environmental Services Director immediately discussed with the two staff who were unaware of the protocols for addressing a grease fire and made them aware of the appropriate procedures to address such an occurrence.