Stairtower Door Failed to Latch Due to Improper Hardware
Penalty
Summary
A deficiency was identified when the first floor stairtower door, located by the South Nurses' Station, failed to latch properly in its frame. This issue was observed during a facility inspection and was attributed to improperly mounted magnet hardware on the door. The failure of the door to positively latch was confirmed during an interview with the Director of Nursing and the Director of Maintenance at the time of the exit conference. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
1. The first floor stair tower door's hardware was adjusted to ensure positive latch. 2. A facility-wide audit was completed to ensure positive latch of required doors. 3. The Environmental Services Director was re-educated on the requirements of K0225. Monthly door latch audits will occur. 4. The NHA or designee will complete a random audit of facility doors weekly x 4 weeks then monthly x 2 months to ensure positive latch. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.