Deficiency in Egress Illumination
Penalty
Summary
During a Life Safety Code recertification survey, it was observed that the facility failed to ensure proper illumination of the means of egress in accordance with NFPA 101 standards. Specifically, on the basement level, the emergency exit discharge located by the Dry Storage Room and the exit leading to the loading dock were both found to be without light fixtures above the doors. Additionally, there were no light fixtures along the path leading to a public way, compromising the continuity of the egress path. These observations were made between 9:30 AM and 2:00 PM, and the findings were acknowledged by the Chief Executive Officer and the Director of Maintenance present during the survey.
Plan Of Correction
Plan of Correction: Approved February 3, 2025 K281 Illumination of Means of Egress 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice Light fixtures were installed above the emergency exit discharge. Light fixtures were installed above the emergency exit discharge located by the Dry Storage Room on the basement level. Light fixtures were installed above the emergency exit discharge leading to the loading dock on the basement level. Additional light fixtures were installed along the path leading to a public way to ensure continuity in the path of egress. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken The following corrective actions will be implemented to identify other residents who may be affected by the same practice: all areas of egress were assessed to ensure proper illumination is in place. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur Hospital Police will add inspection of proper illumination of the means of egress to daily building rounds. Hospital Police has been educated on this new responsibility, on confirming illumination of egress. Regular maintenance checks will be conducted to ensure that all light fixtures are functioning properly and that the means of egress remain illuminated in accordance with NFPA 101. All maintenance staff were in-serviced regarding illumination of means of egress. 4. How the Corrective Action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice All egress areas will be monitored for proper illumination and functionality of the light fixtures monthly for a period of 3 months or until compliance is achieved. The results from the monitoring will be reported to the QAPI Committee. 5. Responsible Individual: Director of Maintenance