Failure to Ensure Exterior Fire Doors Securely Closed After Fire Alarm
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment by ensuring that exterior fire doors in a resident-accessible area were functional and able to securely close. A resident admitted with dementia, repeated falls, and insomnia had been identified as at risk for elopement, and an elopement care plan was in place. A reportable fire event occurred when a bathroom fan on one wing caught fire, triggering the fire alarm system and emergency response. Following this fire alarm, the exterior fire doors on another wing alarmed during the night, and a safety check revealed that the at-risk resident was found outside those exterior fire doors on their hands and knees, with no injuries identified at that time. Subsequent observation of the same exterior fire doors showed that, although they were locked and equipped with a keypad and magnetic locks, one of the two doors did not latch shut on its own and had to be pulled closed to secure it. The Maintenance Director stated that when the fire alarm is activated, the alarms on the exterior fire doors are disabled and the doors open automatically, and acknowledged that the prior fire alarm could have caused the doors to open and then not properly close and latch afterward. He also acknowledged that no one from maintenance checked the exterior fire doors after the fire alarm to ensure they were secured and latched, despite knowing that the doors were old and required pulling to close, and that interior weather stripping might contribute to the failure to close securely. The DNS confirmed that after the fire event, the exterior fire doors were not checked to ensure they were secured and latched.
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