Failure to Secure Egress Doors and Respond Appropriately to Door Alarms
Penalty
Summary
The deficiency involves the facility’s failure to ensure egress doors were properly secured and that staff could effectively respond to and silence door alarms. During an observation with an RN, it was identified that staff were conducting 15‑minute rounds on thirteen egress doors in a rotating pattern that resulted in more than three hours between checks of the same door. While observing Door #8 near the hairdresser, the door alarm sounded and the RN did not know how to silence it. Multiple staff walked past the alarming door without intervening. The RN asked a NA and a housekeeper for assistance, but they reported they did not handle doors or had no information. The Housekeeping Director incorrectly stated the alarm was coming from Door #10, and another housekeeper attempted to silence the alarm at the keypad without success, also believing it was the back door. The alarm at Door #8 continued to sound for an extended period while staff attempted to identify and silence the source. Further observations showed similar issues at Door #10, the back door to the parking lot. After the DON and another staff member initially believed Door #10 was the source of the alarm and then determined it was not, they returned to Door #8 and silenced that alarm with a key. Subsequent observation of Door #10 showed it was secure and alarmed when opened, but entering a code into the keypad did not silence the alarm, and the alarm continued to sound without staff response, even though staff were present in the adjacent kitchen area. The Food Service Director and another staff member later stated they did not respond because they thought it was not the back door alarming, despite acknowledging staff should always respond to an alarming door. Additional observation of Door #12 near the nursing station revealed that entering a code on the keypad turned the indicator light green and allowed the door to open without an alarm, and once opened and closed, the door remained unarmed with no way to re‑arm it from the stairwell side. When the light was red, the door could still be opened without difficulty and no alarm sounded. No facility policy regarding securing egress doors was provided for review.
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.