Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
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Observations:
Name: MAIN BUILDING 01 (GWYNEDD HOUSE) - Component: 01 - Tag: 0222
Based on observation and interview, it was determined the facility failed to maintain emergency exit doors, affecting 1 of 4 emergency exit doors.
Findings Include:
Observation on January 21, 2025, at 11:17 a.m., revealed the emergency exit door next to resident room 40, on the second floor, failed to release after 15 seconds as indicated on sign posted.
Exit Interview with the Administrator and Maintenance Director on Januray 21, 2025, at 12:30 p.m., confirmed failure to maintain emergency exit doors.
| | Plan of Correction - To be completed: 02/10/2025
Outside contractor repaired the emergency exit door next to resident room 40 so that it released after 15 seconds as indicated on the posted sign. This work was completed on January 30, 2025. All emergency exit doors will be audited to ensure their release after 15 seconds as required on a weekly basis for the next 30 days beginning on January 30, 2025 by the Maintenance Director or his designee. All emergency exit doors will then be audited on a monthly basis x 3 months by the Maintenance Director or his designee to ensure compliance. Audits of all emergency exit doors will be completed quarterly thereafter by the Maintenance Director or his designee on an ongoing basis. All audits will be brought to the Quality Assurance & Performance Improvement Committee on a quarterly basis.
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