HospitalInspections.org

Based on review of the Fire Drill Log and interview, it was determined there was no evidence six (first quarter - first and second shifts, third quarter - first and second shifts, and fourth quarter - first and second shifts) of eight required fire drills from January 1, 2017 to December 31, 2017 were performed. Failure to perform required fire drills prevented the facility from ensuring staff were trained and prepared to respond to fire emergencies with required procedures in a prompt and orderly manner to protect patients from fire and smoke. Findings follow:

A. Review of the fire drill documentation provided in the Fire and Safety Manual on 02/27/18 at 9:00 AM showed there was no evidence of a fire drill for:
1) The first quarter, first shift of 2017;
2) The first quarter, second shift of 2017;
3) The third quarter, first shift of 2017;
4) The third quarter second shift of 2017;
5) The fourth quarter, first shift of 2017;
6) The fourth quarter, second shift of 2017.
B. In an interview on 02/27/18 at 1:30 PM, the Director of Maintenance verified there was no further fire drill evidence available for review.

Referenced Code: Life Safety Code NFPA 101, 2012 Edition, Section 19.7.1.6