Fire Door Alarms Disabled and Egress Blocked, Creating Unsafe Environment
Penalty
Summary
The facility failed to maintain a safe and functional environment for residents, staff, and visitors on the 2-West Unit, which had a census of 27 residents, including nine at risk for elopement. The alarm on the stairwell fire door malfunctioned, and instead of repairing it promptly, the alarm was removed and the door was secured shut with zip ties, preventing it from being used as an emergency exit for seven days. Multiple staff members, including nurses, security, and maintenance, were aware of the malfunction and the use of zip ties, but did not escalate the issue to facility leadership in a timely manner. The Director of Nurses and Administrator were not informed until several days later, despite being present in the facility during the period the door was zip tied shut. Further observations revealed that other fire doors throughout the facility also had non-functioning alarms, and at least one fire door did not self-close as required. The facility's posted protocols and policies required that all egress paths remain unobstructed and that accident hazards be identified and removed, but these were not followed. Staff interviews confirmed that the malfunctioning alarms and the use of zip ties were known to several employees, but there was no effective communication or tracking system in place to ensure timely repairs or to alert leadership to the safety hazard. Additionally, surveillance security cameras intended to monitor resident safety were not being continuously monitored by staff, as observed on multiple occasions. The Administrator confirmed that it was her expectation that these cameras be monitored 24/7, and acknowledged that the fire doors should have functioning alarms and be able to close properly. The lack of monitoring and failure to maintain functional fire safety systems contributed to an unsafe environment for residents, staff, and visitors.