Emergency Exit Doors Obstructed with Zip Ties and Gauze
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards by allowing emergency exit doors on two units to be secured shut with zip ties and rolled gauze, preventing egress. The facility's policy required that exit doors remain unlocked and unobstructed at all times to allow for rapid evacuation, and maintenance logs indicated that door operations were checked daily, with no mention of obstructions. However, on the day of the survey, observations revealed that the emergency exit doors on the short halls of two units were physically secured, blocking access to the outside. Multiple staff members, including nurses and aides, were unaware that the emergency exit doors were secured shut. Interviews revealed that the doors would frequently alarm due to high winds, which may have led to the use of zip ties and gauze to prevent the alarms from sounding. Despite this, there was no documentation or communication among staff or management regarding the application of these obstructions, and maintenance staff were also unaware of the situation. The Nursing Home Administrator and DON confirmed they were not aware that the emergency exit doors had been secured in this manner. The deficiency was identified during the survey, and it was determined that the facility's failure to ensure unobstructed emergency exits placed residents in immediate jeopardy of serious harm, as it would have prevented safe egress during an emergency.