Hazardous Area Doors Failing to Self-Close and Latch
Summary
During a Life Safety Code survey, it was observed that hazardous area doors in a facility were not properly self-closing and latching into their door frames. This issue was identified across all four resident use floors, including the basement, first, second, and third floors. Specific doors, such as those to the Precautions Bins Storage Room, Oxygen Storage Areas, Soiled Utility Room, Laundry Room, Central Supply, and Maintenance Shop, were found to have various issues preventing them from closing and latching properly. These issues included stuck latches, doors needing to be pulled to engage the latch, and doors being held open by ropes or magnets. The facility's computerized maintenance system indicated that fire and smoke door inspections were not specific to door locations and were not conducted frequently enough to ensure compliance. Interviews with the Director of Facilities Maintenance and other staff revealed that some doors had been repaired by an outside contractor, but there was no written list of doors assigned for repair. Additionally, the maintenance staff had not been adequately trained on inspecting and maintaining these doors, contributing to the ongoing deficiencies. During a post-survey revisit, it was found that the deficiencies persisted, with doors on the first and third floors still not self-closing and latching. Staff interviews revealed a lack of comprehensive education on the importance of maintaining hazardous area doors, with some staff unaware of the issues or the necessary corrective actions. The facility's Plan of Correction was not fully implemented, and the absence of the Maintenance Director further complicated the resolution of these deficiencies.
Plan Of Correction
Plan of Correction: N/A Corrective action for the deficient doors located on Unit 5 precaution bin storage, Unit 2 oxygen storage area, Unit 3 oxygen storage area, Unit 1 oxygen storage area, Unit 1 soiled utility room, laundry room rear door, central supply door, and the maintenance shop area are corrected or in progress completion by outside contractor. Education will be provided to all staff related to proper door closure and to the maintenance team on proper technique for checking all interior doors. An audit will be conducted for all facility interior doors. This will be logged in the TELS system, and the results will be reported to the QA committee on a monthly basis. Administrator to provide all education and we will continue to monitor the doors monthly and annually. Monitored monthly for 3 months in QA. Responsible designee - Maintenance Director
Penalty
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