Failure to Identify Exit Door Malfunction During Fire Alarm Activation
Penalty
Summary
Facility staff failed to identify and address a malfunction in the exit doors of the Memory Unit, as the doors did not unlock when the fire alarm was activated. This issue was discovered during an observation when staff tested the fire alarm and found that all three exit doors remained locked. The Administrator confirmed in an interview that he was unaware of the malfunction until the fire alarm test was conducted, and stated that his expectation was for staff to have recognized the problem prior to the test. The deficiency was not identified through the facility's Quality Assurance and Performance Improvement (QAPI) process, indicating a lapse in the facility's ability to detect and address quality deficiencies related to emergency preparedness.