Deficiency in Egress Lighting Control
Penalty
Summary
The facility was found to have a deficiency related to the illumination of means of egress in general resident congregation spaces. During a recertification survey, it was observed that the lighting within resident lounges on all nursing units and in the chapel was controlled by manual light switches. These switches had the capability to completely turn off all the lights, which is not compliant with the requirement for continuous illumination of egress paths. This issue was identified during Life Safety inspections conducted over two days, where it was noted that the lighting setup did not prevent manual switches from controlling the lighting in these areas. The facility's Life Safety Director acknowledged the issue during an interview, indicating that the current configuration allowed for the complete shutdown of lighting in critical areas.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 K 281 – Illumination of Means of Egress The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. Immediate Corrective Action for Resident found to be affected by the deficient practice: No residents were affected by the deficient practice. The Medical Director is in agreement that there was no additional risk to residents. The facility corrected the deficiency by reconfiguring the light switches to prevent all lighting being completely turned off within resident lounges on all nursing units and the chapel. 01/17/2025 B) Identification of other Residents having the potential to be affected by the deficient practice: All residents have the potential to be affected by the deficient practice. Review of incident reports revealed no issues as a direct effect of the above-mentioned deficiency. A full house audit will be completed to ensure that other resident congregation spaces have light switches preventing all lighting being turned completely off. Person responsible: Director of Maintenance C) Systemic Changes to ensure the deficient practice will not recur: The Nurse Educator will inservice all facility maintenance staff that all resident congregant spaces must have lighting that are not controlled by manual switches. Education will be verified by posttests or return demonstration to ensure education retention. Person responsible: Nurse Educator QA – Monitor of the deficient practice: Audit tool created to inspect all resident congregant spaces to ensure configuration of light switches to allow illumination of means of egress at all times. This audit will be completed monthly x 3 months and presented to QAPI quarterly. Director of Maintenance is responsible for the correction of this deficiency. Date of correction: 02/18/2025