HospitalInspections.org

Based on document review and staff interview, it was determined the facility failed to conduct fire drills at unexpected times under varying conditions in accordance with NFPA (National Fire Protection Association). This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 3.

Findings include:

a) During the facility document review conducted on 05/13/24 between the hours of 10:30 a.m. and 5:00 p.m., revealed that fire drill conducted from May of 2023 to May of 2024 did not have a sign in sheet to verify that staff participated in the fire drills.

b) During the facility document review conducted on 05/13/24 between the hours of 10:30 a.m. and 5:00 p.m., revealed on the midnight shift fire drill conducted on 4/26/24 at 6:00 a.m. and the fire drill conducted on 5/3/23 at 6:00 a.m. and the fire drill conducted on 6/30/23 at 6:00 a.m. is not at unexpected times under varying conditions.

c) The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 05/14/24 at approximately 4:00 p.m. at the time of exit.