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Based on review of policies and procedures and interview, the Facility failed to assure policies were followed when reporting fires in the operating room. The failed practice did not assure patients and staff were protected from injury related to fire and/or smoke and had the potential to affect all persons in the facility. Findings follow:

A. During interview with the Advanced Practice Partner on 06/02/14 at 1000, she stated facility policy had not been followed, requiring a fire pull be activated nor was a CODE RED called on 04/15/14 when a fire occurred in the Operating Room.

B. Review of Policy, "Fire Safety in Surgical Services" revealed "Steps in Responding to Smoke and/or Actual Fire in the Surgical Services Department: 2. Activate the nearest fire alarm pull station to notify the Fire Department and general alarm system throughout the building. 3. Dial (phone number) and tell Central Control: CODE RED".

C. During interview with the Fire Life Safety Officer on 06/02/14 at 1000, he explained once a fire pull station was activated from a CODE RED, the Fire Department and Safety Office personnel would be alerted and would respond.