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600 HIGHWAY 349 NORTH

IRAAN, TX 79744

EMERGENCY PROCEDURES

Tag No.: C0227

It was determined that the critical access hospital failed to ensure the safety of patient in non-medical emergencies, as evidence by inadequate training of personnel regarding fire drills including the use of fire alarm and evacuation of patients.

Findings were:

During a review of fire drill documentation for the time period of 12-1-2010 through 11-1-2011, there was only documentation of one fire drill. This documentation gave no indication that the evacuation of patients was simulated during the drills or that the alarm system was utilized in the drill.

An interview with facility administrator on 11-30-11, confirmed that evacuation of patients was not simulated and alarms were not utilized during the drills.