Failure to Provide Emergency Illumination
Penalty
Summary
The facility failed to provide emergency illumination in accordance with the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8, on two of three units and the core area. Specifically, during observations, it was noted that the light switches controlling normal and emergency lighting for the means of egress and exit access did not provide lighting when the switch was in the off position in the A-Wing TV Lounge, the core area main dining room, and the C-Wing Physical Therapy room. Additionally, emergency lighting was absent along the path of egress to the public way from the C-Wing RN station exit and along the south driveway. Furthermore, the light fixture cover at the C-Wing north exit discharge was broken, exposing the light bulb. These deficiencies were confirmed through interviews with the Maintenance and Life Safety Consultant and the Administrator.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) The facility will install emergency lighting along the egress path from C-wing nursing station exit and along the south driveway leading to the public way. The light fixture cover at the C-Wing north exit discharge was replaced on 12/18/2024. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. The administrator and maintenance director completed external rounds of the facility to ensure emergency lighting was present along all means of egress to the public way. No additional areas were identified. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) Monthly monitoring of lighting and fixtures at exit discharges and paths leading to the public way has been added to the preventative maintenance schedule. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) The monthly preventative maintenance monitoring of lighting will be presented to the Quality Assurance Performance Improvement Committee monthly for four months for review and additional recommendations for interventions and duration of audits will be given as needed. Responsible Party: Director of Maintenance