Failure to Document Required Emergency Lighting Tests
Penalty
Summary
The facility failed to provide documentation that all battery-powered emergency lighting was tested annually for 90 minutes and function tested monthly for 30 seconds, as required by NFPA 101, 7.9.3.1.1. During a record review, no activity reports or documentation of these tests were available for surveyor review. These findings were confirmed through an interview with the Director of Facilities at the time of the record review. No information regarding specific patients, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
K291 Emergency Lighting Element 1: Action taken to identify residents: No residents were identified. Element 2: Identification of other residents: All occupants could be affected in the event of an electrical power failure. Element 3: (1) Measures Taken: The Administrator or designee will conduct and document the needed annual 90-minute testing of the facility's battery-operated emergency lighting. Element 3: (2) Measures Taken: The Administrator or designee will conduct and document the needed monthly 30-second testing of the facility's battery-operated emergency lighting. Element 4: Monitoring: The Administrator or designee will compile a report of the battery-operated emergency lighting test for review and recommendations by the Quality Assurance Performance Improvement Committee monthly, three times, and periodically thereafter. The Administrator will assume responsibility for attained compliance.