Improper Exit Signage and Documentation Issues
Penalty
Summary
During a Life Safety Code survey, it was observed that required exit signs in a long-term care facility did not correctly indicate the egress path, affecting both the first and second floors used by residents. On the second floor, an illuminated exit sign in the Activities Suite was mounted perpendicular to the suite entrance, with the word 'Exit' illuminated on both sides but without chevrons to indicate the correct path of egress. This misled individuals to believe the path of egress was into rooms without exits. The Director of Plant Operations confirmed that the chevrons should have been lit to indicate the main suite entrance as the egress path. Similar issues were found on the first floor in the 1 West and 1 East Units, where exit signs at stairway entrances lacked illuminated chevrons, misleading individuals to believe the path of egress was at the end of corridors with no exits. The Director of Long Term Care Facilities noted that many exit signs had been replaced months prior. Additionally, there was a lack of documented checks of illuminated exit signs, as confirmed by the Director of Plant Operations and the Administrator, despite claims from a Maintenance Technician that checks were conducted weekly.
Plan Of Correction
Plan of Correction: Approved January 31, 2025 Corrective action for affected area: The plant operations director corrected activities in the suite, 1 West Unit north/south stairway, 1 East Unit north and south stairway, and 2 West Unit north and south stairways exit sign chevrons so they illuminated and indicate the path of egress. Steps to prevent further recurrence: A walk-through of the facility has been conducted to identify any exit signs that needed adjustment; any needed corrections were made. Steps to prevent further recurrence: Use of a monthly exit sign audit where the auditor ensures the sign reflects the correct direction. Maintenance staff will be educated on the importance of ensuring the illuminated exit signs properly identify the path of egress. How corrective action will be monitored: Audits will be reviewed by administration and reported to the quality assurance committee. The plant operations director will be responsible for correction.