|Means of Egress - General|
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 220.127.116.11
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211
Based on observation and interview the means of egress was not free from all obstructions in one instance affecting one of five floors within the facility.
1. Observation on January 22, 2019, at 11:35 a.m., revealed a stationary chair placed in the third-floor, corridor near resident room #321.
Exit interview with the facility representatives #1, 2, 3, and 4, on January 22, 2019, between 3:30 p.m. and 3:45 p.m., confirmed the egress obstruction.
| ||Plan of Correction - To be completed: 01/23/2019|
K2011 Means of Egress - General
2) What systematic changes will be put into place to ensure that the deficiency does not recur, and how the corrective action(s) will be monitored;
The stationary chair was removed near Room 321 on January 22, 2019.
3. How the facility plans to monitor its performance to make sure that solutions are sustained.
The Maintenance Director or designee will conduct random focus audit of Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7. obstructions. Reports will be submitted to the Quality Assurance committee.