Deficient Fire Barrier Door Closure in Hazardous Area
Penalty
Summary
The facility failed to maintain the required fire safety standards for hazardous area enclosures in one of five smoke compartments. During an observation, it was found that the door to the South Nurses' Station and Food Storage Room did not automatically close and latch within the door frame due to a faulty door closure. This deficiency was confirmed during an interview with the Director of Nursing and the Director of Maintenance, who acknowledged that the door failed to function as required.
Plan Of Correction
1. The South Nurses Station and Food Storage Room door closure 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 K0321. 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. K 0321