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 - Component: 01 - Tag: 0222
Based on observation and interview, the facility failed to maintain egress on two of three floors.
Findings include:
Observation on February 21, 2024, between 10:05 a.m. and 11:22 a.m., revealed the following:
a. 10:05 a.m., second floor, nurse restroom at nurse station was installed with deadbolt lock. b. 11:20 a.m., first floor, exit door at the stair tower, located near room B-126, required excessive force to open. c. At 11:22 a.m., first floor, nurs restroom at the nurse station was installed with deadbolt lock.
Exit interview with the facility administrator and the facilities manager on February 21, 2024, at 12:30 p.m., confirmed the egress doors defiencies.
| | Plan of Correction - To be completed: 04/15/2024
The identified doors with deadbolts were immediately removed during the time of survey and replaced with standard approved door locks. The Director of maintenance and designees checked all other similar doors for deadbolt use, no there were identified. The director of maintenance educated the staff of the maintenance department that the use of dead bolts would not be allowed. during monthly compliance rounds appropriate locks on doors will now be added to the checklist. any unapproved locks will be replaced immediately. The results of the monthly compliance rounds will be discussed/reviewed at the AQPI meeting.
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