Failure to Maintain Life Safety Documentation and Carbon Monoxide Alarm Protocols
Penalty
Summary
Surveyors identified several deficiencies related to the facility's compliance with general requirements for life safety and state regulations. The facility failed to provide updated and accurate life safety floor plans when requested during the survey. Both the Director of Nursing and the Director of Maintenance confirmed at the exit conference that the facility could not produce these required documents. Additionally, the facility did not have documentation verifying that annual testing and inspection of installed carbon monoxide alarms had been performed according to the manufacturer's instructions, as required by the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act. A Nighthawk battery-operated carbon monoxide detector was observed at the main desk, but no supporting documentation was available. Further, the facility lacked documentation verifying the existence and implementation of evacuation and alarm protocols related to carbon monoxide alarms, also in accordance with the 2016 Act 48. This was confirmed during interviews with facility leadership, who acknowledged the absence of required documentation for both annual inspections and evacuation/alarm protocols. No information about specific residents or their conditions was included in the report.
Plan Of Correction
1. Life Safety floor plan drawings have been updated and are available for review. Carbon monoxide alarms throughout the facility will receive their annual testing per the manufacturer's instructions. Evacuation and alarm protocols are available for review. 2. The facility has updated its floor plan drawings and made available its evacuation and alarm protocols. These items are posted in the Emergency Preparedness Manual. 3. The Environmental Services Director was re-educated on the requirements of K0100. The carbon monoxide alarms will be tested annually in July. The Emergency Preparedness Manual will be reviewed quarterly and PRN for accuracy. 4. The NHA or designee completed a one-time audit of the Emergency Preparedness Manual to ensure that floor plan drawings and evacuation/alarm protocols were available. The NHA or designee will complete an annual audit of the Carbon Monoxide alarm testing in July x 2 years. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.