Lack of Battery-Backed Emergency Lighting at Generator Transfer Switch
Penalty
Summary
A deficiency was identified during an inspection of the Main Electrical room, where it was observed that there was no battery-backed emergency lighting installed for the emergency generator's transfer switch. This emergency lighting is required to function independently of both the building's electrical system and the emergency generator, in accordance with NFPA 101:2012 standards. The absence of this lighting was confirmed through observation and interview with facility staff. The deficiency had the potential to affect 117 residents, as noted during the Life Safety Code survey.
Plan Of Correction
1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: A functioning battery emergency light was installed at the emergency transfer switch location. Battery is independent of the building's electrical system and emergency generator system. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The U.S. FOIA (b) (6) was educated on K291 to ensure compliance is maintained by the Administrator. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: Administrator or Designee will ensure that the emergency backup light at transfer switch is and remains operational. Audits will be conducted on a monthly basis. Findings will be reported to the QAPI committee meeting until compliance has been met.