Blocked Exit Door and Water Intrusion Create Unsafe Egress Route
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and unobstructed exit and to prevent water intrusion that created an unsafe exit route in a shared resident room. Surveyors observed that one resident’s bed was positioned so that the head of the bed partially blocked a door marked with signage as an emergency exit, stating “Exit WARNING!! ALARM WILL SOUND EMERGENCY EXIT ONLY!” This door was identified in the facility’s Disaster and Evacuation Plan as an exit leading to a back patio. The facility’s Fire and Disaster Policy/Procedure required that exit ways be kept clear at all times and that exit doors never be blocked, but this requirement was not followed in the room occupied by four residents. Resident 1, who had a displaced transverse fracture of the right patella, moderately impaired cognition, and required supervision or touch assistance with ADLs, had been assigned to the current bed for several days. During observation, her bed was found positioned halfway blocking the exit door. Resident 1 reported that on a recent day of heavy rain, water flooded the floor near her bed, and her clothing became wet. She believed the water came in from under the exit door and stated that she hung her wet clothes on a chair to dry because she was concerned they could develop mildew and odors. Residents 3, 6, and 7 also occupied the same room and all had severely impaired cognition and required substantial to total assistance with ADLs. The Maintenance Supervisor confirmed that the exit door was unlocked, operable via the push bar, and led to a back patio, and acknowledged that Resident 1’s bed was partially blocking the exit and would need to be moved for full access in an emergency. He stated that flooding had been reported to him after it occurred, that housekeeping had already mopped and placed towels, and that the flooding was caused by heavy rain entering under the exit door, wetting some of Resident 1’s clothing that was kept on the floor. He also stated that no changes were made to the door to prevent future flooding. The DON and Administrator both stated that, despite the door being marked as an exit on the floor map, it was not considered part of the emergency exit plan and staff were not trained to use it during emergencies, while also acknowledging that having an exit door by the bed could impact resident safety.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.