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 (ORIG. BLDG. & NEW ADD.) - Component: 01 - Tag: 0222
Based on observation and interview, it was determined the facility failed to maintain delayed egress doors, affecting one of eight levels in the facility.
Findings include:
Observation on March 5, 2024, at 10:20 a.m., revealed, on the fourth floor, the delayed egress door near resident room 413 failed to open after 15 seconds.
Exit interview with the Administrator and the Maintenance Director on March 5, 2024, at 11:15 a.m., confirmed the door failed to open.
| | Plan of Correction - To be completed: 04/22/2024
1. An outside vendor will be contracted to make door repairs to maintain delayed egress locking systems to be in accordance to open after 15 seconds on the fourth floor (near room 413). 2. The appropriate staff will be in-serviced to maintain delayed egress to open after 15 seconds by April 22, 2024. 3. The Environmental Service Director or designee will audit compliance weekly for four weeks and then monthly for two months. 4. The results of the in house audit will be reviewed at the QAPI meeting for three months.
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