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ADVENTIST HEALTH REEDLEY
No Description Available
Tag No.: K0050
Based on interview and document review, the facility failed to conduct fire drills at least quarterly, on each shift, as evidenced by 2 of 12 missing fire drills during a twelve month period. This could lead to staff not understanding the evacuation procedures in the event of an emergency and affected four of four smoke compartments.
NFPA 101, Life Safety Code, 2000 Edition
19.7.1.2* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.
Findings:
During document review with Facilities Manager on 7/5/16, the fire drill records were reviewed.
1. At 3:10 p.m., fire drills for the PM shift and NOC shift for the 3rd quarter of 2015 were not provided. When interviewed, the Facilities Manager stated that the person doing the fire drills at that time didn't know that the drills had to be done on each shift and conducted them all at one time. All fire drills since had been conducted once per shift per quarter.
LIFE SAFETY CODE STANDARD
Tag No.: K0050
Based on interview and document review, the facility failed to conduct fire drills at least quarterly, on each shift, as evidenced by 2 of 12 missing fire drills during a twelve month period. This could lead to staff not understanding the evacuation procedures in the event of an emergency and affected four of four smoke compartments.
NFPA 101, Life Safety Code, 2000 Edition
19.7.1.2* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.
Findings:
During document review with Facilities Manager on 7/5/16, the fire drill records were reviewed.
1. At 3:10 p.m., fire drills for the PM shift and NOC shift for the 3rd quarter of 2015 were not provided. When interviewed, the Facilities Manager stated that the person doing the fire drills at that time didn't know that the drills had to be done on each shift and conducted them all at one time. All fire drills since had been conducted once per shift per quarter.