Failure to Document Monthly Exit Signage Inspections
Penalty
Summary
The facility failed to maintain documentation verifying that exit signage was subjected to monthly visual inspections over the previous twelve months. This deficiency was identified during a document review and interview conducted on December 18, 2024, at 10:35 AM. The Maintenance Manager confirmed the absence of documentation for these inspections, which affects the entire component of the facility's exit signage system. This lack of documentation indicates non-compliance with the requirement for continuous illumination of exit signs, as stipulated by NFPA 101 Exit Signage standards.
Plan Of Correction
Life Safety Code, NFPA 101 Exit Signage: 1. A monthly inspections of exit signage (426) has been created in the work order system to ensure all exit signage are visually inspected. 2. Team Member will visually inspect exit signage at least once per month. 3. Team Member will document completion of inspection after each occurrence. 4. The deficiency and the new process for monthly inspections (426) has been reviewed with the Lakeside Maintenance team members. 5. The corrective action will be document and monitored by our Facility Management work order system. The documentation and reports will be reviewed at Quality Assurance meeting in 2025. 6. POC date of compliance will be completed by January 31st, 2025.