HospitalInspections.org

Based on record review and interview, the provider failed to conduct quarterly fire drills during the first, second, or third shifts during the third quarter of 2017. Findings include:

1. Fire drill record review at 10:15 a.m. on 4/17/18 revealed no documentation indicating a fire drill was conducted for the first shift (7:00 a.m. to 3:00 p.m.), second shift (3:00 p.m. to 11:00 p.m.), or third shift (11:00 p.m. to 7:00 a.m.) during the third quarter (July through September 2017).

Interview with the maintenance supervisor at the time of the record review confirmed those findings. He indicated the facility was doing a fire watch during that period. The staff person assigned to complete the fire drills assumed that fire drills were not necessary.

The deficiency had the potential to affect 100% of the occupants of the building.