Failure to Ensure Continuous Illumination in Egress Pathway
Penalty
Summary
The facility failed to ensure continuous illumination in the means of egress as required by NFPA 101 standards. During a Life Safety recertification survey, it was observed that the wall-mounted light switches in the Rehab corridor, when turned off, extinguished all the lights in the corridor leading to an emergency stairwell exit. This issue was identified on one of the two resident floors. The Director of Maintenance acknowledged the finding during an interview, stating that the corridor lights would be continuous.
Plan Of Correction
Plan of Correction: Approved April 10, 2025 K281 I. Immediate Corrective Action: 1. Rehab Corridor Lighting: - The Maintenance director immediately contacted an electrician to address the lighting issue in the Rehab corridor, powering every other light for clear illumination of egress. - The wall-mounted light switches that were controlling the lights leading to the emergency stairwell exit have been re-wired to ensure that the illumination in the means of egress is continuous, even when the light switches are turned off. II. Identification of Others: - All residents have the potential to be affected. However, none were. - All other egress routes were found to be compliant. - The Director of Maintenance conducted a review of all light switches and emergency exit routes on both residents’ floors to ensure compliance with NFPA 101, identifying and addressing any similar concerns. III. Systemic Changes: 1. The Director of Maintenance reviewed the facility's Life Safety procedures, ensuring maintenance staff are trained in NFPA 101 requirements for the illumination of means of egress. The training included instructions on how to ensure continuous illumination for safe exits. - Maintenance staff were re-educated on the importance of maintaining proper lighting on all exit routes, with an emphasis on the emergency stairwell. 2. Regular checks on all emergency lighting systems during routine inspection were added to the routine maintenance checklist ensuring all corridors and exits are properly illuminated and compliant with NFPA 101. IV. Quality Assurance: 1. A tracking tool was developed by the Director of Maintenance to ensure ongoing compliance with lighting and means of egress standards. 2. Monthly audits of all exit routes will begin to ensure that lighting remains compliant with NFPA 101, and any identified issues will be corrected promptly. 3. The results of the monthly audits will be reviewed during QAPI and reported quarterly. V. Person Responsible: - Director of Maintenance