Lack of Documentation for Monthly Exit Sign Inspections
Penalty
Summary
Surveyors determined that the facility failed to provide documentation verifying that monthly visual inspections of exit signs had been conducted over the past 12 months. During a document review, it was found that there was no record of these required inspections. This finding was confirmed in an interview with the DON and the Director of Maintenance, who acknowledged that the facility could not produce the necessary documentation for exit sign inspections. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was included in the report.
Plan Of Correction
1. The facility is unable to retroactively perform this testing. 2. A monthly exit sign inspection was completed in July. 3. The Environmental Services Director was re-educated on the requirements of K0293. Monthly exit sign inspections are scheduled. 4. The NHA or designee will complete an audit of exit sign inspection documentation monthly x 6 months. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.