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Based on observation and interview, it was determined the facility failed to maintain the locking mechanism on a door to a seclusion room, sometimes used as a patient sleeping room, per NFPA standards. The deficiency had the potential to affect one (1) smoke compartment, one (1) patient and staff. The facility is licensed for eighty-eight (88) beds; the census on the day of the survey was eighty-three (83).



The findings include:

Observation during the facility tour on 05/13/2011, between 12:30 PM and 1:30 PM, with the Chief Operations Officer, Director of Nursing, and the Compliance Officer, revealed three (3) unapproved locks (heavy duty slide bolt type) installed on the egress side of the door to a seclusion room, which was sometimes used as a patient sleeping room.

Interview on 05/13/2011, at 12:30 PM, with the Chief Operations Officer, Director of Nursing, and Compliance Officer, revealed that a patient had slept in the seclusion room, with the door in the open position and observed during fifteen (15) minute intervals.

Further observation and interview, with the Maintenance Director on 05/13/2011, at 1:40 PM, indicated that slide bolt locks were only installed on the seclusion room in the older area of the facility. The other seclusion rooms within the newer area of the facility can be locked by key only.




Reference:

NFPA 101 (2000 Edition)

19.2.2.2.2
Locks shall not be permitted on patient sleeping room doors.
Exception No. 1: Key-locking devices that restrict access to the room from the corridor and that are operable only by staff from the corridor side shall be permitted. Such devices shall not restrict egress from the room.
Exception No. 2: Door-locking arrangements shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that keys are carried by staff at all times.
19.2.2.2.3
Doors not located in a required means of egress shall be permitted to be subject to locking.
19.2.2.2.4
Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5.)
Exception No. 2*: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.
19.2.2.2.5
Doors located in the means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made for the rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all times, or other such reliable means available to the staff at all times. Only one such locking device shall be permitted on each door.
Exception No. 1: Locks in accordance with Exception Nos. 2 and 3 to 19.2.2.2.4.
Exception No. 2: More than one lock shall be permitted on each door subject to approval of the authority having jurisdiction.

Based on observation and interview, it was determined the facility failed to maintain the locking mechanism on a door to a seclusion room, sometimes used as a patient sleeping room, per NFPA standards. The deficiency had the potential to affect one (1) smoke compartment, one (1) patient and staff. The facility is licensed for eighty-eight (88) beds; the census on the day of the survey was eighty-three (83).



The findings include:

Observation during the facility tour on 05/13/2011, between 12:30 PM and 1:30 PM, with the Chief Operations Officer, Director of Nursing, and the Compliance Officer, revealed three (3) unapproved locks (heavy duty slide bolt type) installed on the egress side of the door to a seclusion room, which was sometimes used as a patient sleeping room.

Interview on 05/13/2011, at 12:30 PM, with the Chief Operations Officer, Director of Nursing, and Compliance Officer, revealed that a patient had slept in the seclusion room, with the door in the open position and observed during fifteen (15) minute intervals.

Further observation and interview, with the Maintenance Director on 05/13/2011, at 1:40 PM, indicated that slide bolt locks were only installed on the seclusion room in the older area of the facility. The other seclusion rooms within the newer area of the facility can be locked by key only.




Reference:

NFPA 101 (2000 Edition)

19.2.2.2.2
Locks shall not be permitted on patient sleeping room doors.
Exception No. 1: Key-locking devices that restrict access to the room from the corridor and that are operable only by staff from the corridor side shall be permitted. Such devices shall not restrict egress from the room.
Exception No. 2: Door-locking arrangements shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that keys are carried by staff at all times.
19.2.2.2.3
Doors not located in a required means of egress shall be permitted to be subject to locking.
19.2.2.2.4
Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5.)
Exception No. 2*: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.
19.2.2.2.5
Doors located in the means of egress that are permitted to be locked under other provisions of this chapter shall have adequate provisions made for the rapid removal of occupants by means such as remote control of locks, keying of all locks to keys carried by staff at all times, or other such reliable means available to the staff at all times. Only one such locking device shall be permitted on each door.
Exception No. 1: Locks in accordance with Exception Nos. 2 and 3 to 19.2.2.2.4.
Exception No. 2: More than one lock shall be permitted on each door subject to approval of the authority having jurisdiction.