HospitalInspections.org

34000

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The facility failed to document staff participation in the fire drills. Findings include:

During the survey, the following is an example of what was observed:
Per documentation and interview, the facility was not getting all staff to sign the participation sheets. The participation sheets for the drills conducted on 10/9/2013, and 12/20/2013, were blank.

During the revisit the facility failed to provide documentation for the second shift fire drill for the first quarter of 2015. The facility has only two shifts.
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NFPA 101, 19.7.1.2 and 19.7.1.3 Drills shall include proper procedures, making sure all staff members participate.

NFPA 101, 19.7.1.2 Drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts to simulate the unusual conditions occurring in case of fire.

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