HospitalInspections.org

Based on facility observation, review of facility documentation and staff interview the facility failed to ensure that fire drills included the transmission of a fire alarm signal and simulation of emergency fire conditions, fire drills were to be held at unexpected times under varying conditions, at least quarterly on each shift, staff are to be familiar with procedures and aware that drills are part of established routine, responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership and where drills are conducted between 9:00 PM and 6:00 AM a coded announcement may be used instead of audible alarms. This finding could potentially affect all 16 patients.

Findings included:

1. On 06/14/16 at 10:00 A.M. interview of Staff D revealed the facility provided care for patients who required special locking arrangements on exit doors due to their clinical needs. These exit doors were magnetically locked and required staff to have key cards in order to access and leave the facility. Staff D stated the doors were a component of the fire alarm system in that, when activated, the doors were released allowing for exit discharge from the facility. Staff D stated that all staff had key cards in their possession in order to enter and leave the facility. A card reader at each exit door released the door when the card was recognized.

Interviews of staff were conducted regarding the fire procedures for the locked facility. Three nursing assistants and one registered nurse assigned for patient care on 06/14/16 and 06/15/16 were interviewed regarding use of keys on the unit. The three nursing assistants interviewed stated they had "aide keys" which had a limited number of keys. Each nursing assistant stated the keys were passed on from one shift to the next.

Staff K was interviewed on 06/14/16 at 11:20 A.M. regarding the function of the keys in his/her possession. Staff K stated there was no key that locked and unlocked patient rooms. She stated her keys opened supply closets and shower rooms. Staff was asked to try to lock a patient room. Staff K selected a larger key which successfully locked and unlocked a randomly selected patient room door. Further interview regarding the "aide keys" revealed a smaller, red coded key. Staff K revealed the red coded key was for the secured pull stations of the fire alarm system and that another key (silver key) was for the fire extinguisher cabinet located in the corridor. Staff K stated he/she did not have the silver key as it was dropped outside when on break. Staff K was asked to try the red coded key in the fire extinguisher cabinet. The key opened the cabinet. Staff K was unable to specify the procedure to be followed if the fire alarm were activated. Further interview of Staff K revealed a hire date less than three months ago.

Staff G was interviewed regarding the set of keys in his/her possession. Staff G was asked to demonstrate how to open the locked fire extinguisher cabinet. A red band was hanging freely between two smaller keys on the set of keys. Staff G stated the red band belonged to the key which unlocked the cabinet for patient snacks. Staff D later confirmed the key to the fire extinguisher cabinet was the same key which opened the cupboard for patient snacks. Staff G was asked to try the key in the lock for the fire extinguisher cabinet. The key opened the cabinet. Staff G stated the other small key must be for the fire alarm pull stations.

Review of fire drill documentation from December 2015 until May 2016 revealed eight fire drills conducted. Documentation of a fire drill conducted 12/20/15 at 5:30 A.M. revealed a critique of the drill that noted it would be helpful if staff could pull a pull station.

Staff D was interviewed on 06/15/16 at 3:32 P.M. regarding fire drill documentation in December 2015 which noted that utilizing a pull station would be helpful. Staff D confirmed that staff education regarding the keys was provided on 03/14/16 and 03/15/16 during an in-service, however, the facility has not activated a pull station for a fire drill. Staff D revealed that resetting a pull station that required a key to release the secured cover of the pull station was very difficult.

2. On 06/14/16 review of documented fire drills conducted since December 2015 was completed. The facility documentation included sections of the fire drill that were to be evaluated. Page one included the time the alarm company was notified of the drill and the area affected for the drill/fire. Section two, of page one, included an area to document what time the pull station was pulled. Section 3, page two of the fire drill report, was labeled the "All Clear". This section was to note the time the alarm was reset and the time the alarm company was notified of the all clear. Items 4 and 5 of the section were to note if the alarm company received the signal and if the company received the signal for the correct pull station.

Review of the eight fire drills documented between December 2015 and April 19, 2016 revealed that five of the eight drills did not contain completed information as follows:

a. The fire drill dated 02/08/16, conducted at 5:30 P.M. had no noted time the alarm company was notified of the drill. Page two, section 3, noted the time the alarm was reset, the time the alarm company was notified of the all clear, if the alarm company received the signal and if the company received the signal for the correct pull station was blank.
Review of the central monitoring system event report revealed the signal was received at 6:26:12 PM for a test.

b. The fire drill dated 02/24/16, conducted at 1800. had no noted time the alarm company was notified of the drill or if a pull station was pulled. Page two, section 3, which noted the time the alarm was reset, the time the alarm company was notified of the all clear, if the alarm company received the signal and if the company received the signal for the correct pull station was blank.

Review of the central monitoring system event report revealed the signal was received at 6:40:01 PM for a test.

c. The fire drill dated 02/25/16, conducted at 8:30 P.M. had no affected area identified, the time the alarm company was notified of the drill or if a pull station was pulled. Page two of the form was missing.

d. The fire drill dated 04/19/16, conducted at 10:54 A.M. had no affected area identified and no time the alarm company was notified of the drill.

e. The fire drill dated 05/16/16, conducted at 7:20 PM had no noted time the alarm company was notified of the drill. Page two, section 3, did not note the time the alarm company received the signal and if the company received the signal for the correct pull station.

Interview of Staff D on 06/15/16 at 3:32 P.M. regarding the documentation of fire drills confirmed the drill information was incorrectly completed with inaccurate information and/or incomplete information.

Based on facility observation, review of facility documentation and staff interview the facility failed to ensure the fire alarm system that is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building, the fire alarm system wiring or other transmission paths were to be monitored for integrity, initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system, manual alarm boxes are provided in the path of egress near each required exit, manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations, occupant notification is provided by audible and visual signals, the fire alarm system transmits the alarm automatically to notify emergency forces in the event of fire, the fire alarm automatically activates required control functions and system records were to be maintained and readily available. This finding potentially could affect all 16 patients.

Findings included:

1. On 06/14/16 at 10:00 A.M., Staff D was interviewed regarding the fire alarm system. Staff D stated the fire alarm system was interconnected with the fire alarm system for the adjoining skilled nursing facility. Staff D stated the maintenance staff of the skilled facility worked with this facility to coordinate fire drills and that information was exchanged regarding the fire drills.

Staff D revealed the facility provided care for patients who required special locking arrangements on exit doors due to their clinical needs. These exit doors were magnetically locked and required staff to have key cards in order to access and leave the facility. Staff D stated the doors were a component of the fire alarm system in that, when activated, the doors were released allowing for exit discharge from the facility. Staff D stated the doors were tested during fire drills to ensure proper release in the event of an actual emergency.

Tour of the facility with Staff D on 06/14/16, revealed that all staff had key cards in their possession in order to enter and leave the facility. A card reader at each exit door released the door when the card was recognized. Observation of an exit from the common area near the nursing station lead to an enclosed courtyard. A gate, designated as an exit, lead to the public way from the courtyard, was also equipped with the magnetic lock. Staff D confirmed the gate also released with activation of the fire alarm system. Staff D stated that during fire drills, when the alarm was activated, staff are posted at exit doors to ensure that patients do not elope.

Review of documented fire drills revealed no evidence of testing for release of the magnetic locks on the exit doors. On 06/15/16 at 9:00 A.M. Staff D confirmed there was no documentation to confirm testing for release of the exit doors.

2. On 06/14/16 review of documented fire drills conducted since December 2015 was completed. The facility documentation included sections of the fire drill that were to be evaluated. Page one of the documented included the time the alarm company was notified of the drill and the area affected for the drill/fire. Section two, of page one, included an area to document what time pull station was pulled. Section 3, page two of the fire drill report, was labeled the "All Clear". This section was to note the time the alarm was reset and the time the alarm company was notified of the all clear. Items 4 and 5 of the section were to note if the alarm company received the signal and if the company received the signal for the correct pull station.

Review of the eight fire drills documented between December 2015 and April 19, 2016 revealed that five of eight drills did not contain completed information. The following five fire drills lacked completed documentation as follows:

a. The fire drill dated 02/08/16, conducted at 5:30 P.M. had no noted time the alarm company was notified of the drill. Page two, section 3, which noted the time the alarm was reset, the time the alarm company was notified of the all clear, if the alarm company received the signal and if the company received the signal for the correct pull station was blank.

Review of the central monitoring system event report revealed the signal was received at 6:26:12 PM for a test.

b. The fire drill dated 02/24/16, conducted at 6:00 PM had no noted time the alarm company was notified of the drill or if a pull station was pulled. Page two, section 3, which noted the time the alarm was reset, the time the alarm company was notified of the all clear, if the alarm company received the signal and if the company received the signal for the correct pull station was blank.

Review of the central monitoring system event report revealed the signal was received at 6:40:01 PM for a test.

c. The fire drill dated 02/25/16, conducted at 8:30 P.M. had no affected area identified, the time the alarm company was notified of the drill or if a pull station was pulled. Page two of the form was missing.

d. The fire drill dated 04/19/16, conducted at 10:54 A.M. had no affected area identified and no time the alarm company was notified of the drill.

e. The fire drill dated 05/16/16, conducted at 1920 had no noted time the alarm company was notified of the drill. Page two, section 3, did not note the time the alarm company received the signal and if the company received the signal for the correct pull station.

Interview of Staff D on 06/15/16 at 3:32 P.M. regarding the documentation of fire drills confirmed the drill information was incorrectly completed with inaccurate information and/or incomplete information.

Based on facility observation, review of facility documentation and staff interview the facility failed to ensure that fire drills included the transmission of a fire alarm signal and simulation of emergency fire conditions, fire drills were to be held at unexpected times under varying conditions, at least quarterly on each shift, staff are to be familiar with procedures and aware that drills are part of established routine, responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership and where drills are conducted between 9:00 PM and 6:00 AM a coded announcement may be used instead of audible alarms. This finding could potentially affect all 16 patients.

Findings included:

1. On 06/14/16 at 10:00 A.M. interview of Staff D revealed the facility provided care for patients who required special locking arrangements on exit doors due to their clinical needs. These exit doors were magnetically locked and required staff to have key cards in order to access and leave the facility. Staff D stated the doors were a component of the fire alarm system in that, when activated, the doors were released allowing for exit discharge from the facility. Staff D stated that all staff had key cards in their possession in order to enter and leave the facility. A card reader at each exit door released the door when the card was recognized.

Interviews of staff were conducted regarding the fire procedures for the locked facility. Three nursing assistants and one registered nurse assigned for patient care on 06/14/16 and 06/15/16 were interviewed regarding use of keys on the unit. The three nursing assistants interviewed stated they had "aide keys" which had a limited number of keys. Each nursing assistant stated the keys were passed on from one shift to the next.

Staff K was interviewed on 06/14/16 at 11:20 A.M. regarding the function of the keys in his/her possession. Staff K stated there was no key that locked and unlocked patient rooms. She stated her keys opened supply closets and shower rooms. Staff was asked to try to lock a patient room. Staff K selected a larger key which successfully locked and unlocked a randomly selected patient room door. Further interview regarding the "aide keys" revealed a smaller, red coded key. Staff K revealed the red coded key was for the secured pull stations of the fire alarm system and that another key (silver key) was for the fire extinguisher cabinet located in the corridor. Staff K stated he/she did not have the silver key as it was dropped outside when on break. Staff K was asked to try the red coded key in the fire extinguisher cabinet. The key opened the cabinet. Staff K was unable to specify the procedure to be followed if the fire alarm were activated. Further interview of Staff K revealed a hire date less than three months ago.

Staff G was interviewed regarding the set of keys in his/her possession. Staff G was asked to demonstrate how to open the locked fire extinguisher cabinet. A red band was hanging freely between two smaller keys on the set of keys. Staff G stated the red band belonged to the key which unlocked the cabinet for patient snacks. Staff D later confirmed the key to the fire extinguisher cabinet was the same key which opened the cupboard for patient snacks. Staff G was asked to try the key in the lock for the fire extinguisher cabinet. The key opened the cabinet. Staff G stated the other small key must be for the fire alarm pull stations.

Review of fire drill documentation from December 2015 until May 2016 revealed eight fire drills conducted. Documentation of a fire drill conducted 12/20/15 at 5:30 A.M. revealed a critique of the drill that noted it would be helpful if staff could pull a pull station.

Staff D was interviewed on 06/15/16 at 3:32 P.M. regarding fire drill documentation in December 2015 which noted that utilizing a pull station would be helpful. Staff D confirmed that staff education regarding the keys was provided on 03/14/16 and 03/15/16 during an in-service, however, the facility has not activated a pull station for a fire drill. Staff D revealed that resetting a pull station that required a key to release the secured cover of the pull station was very difficult.

2. On 06/14/16 review of documented fire drills conducted since December 2015 was completed. The facility documentation included sections of the fire drill that were to be evaluated. Page one included the time the alarm company was notified of the drill and the area affected for the drill/fire. Section two, of page one, included an area to document what time the pull station was pulled. Section 3, page two of the fire drill report, was labeled the "All Clear". This section was to note the time the alarm was reset and the time the alarm company was notified of the all clear. Items 4 and 5 of the section were to note if the alarm company received the signal and if the company received the signal for the correct pull station.

Review of the eight fire drills documented between December 2015 and April 19, 2016 revealed that five of the eight drills did not contain completed information as follows:

a. The fire drill dated 02/08/16, conducted at 5:30 P.M. had no noted time the alarm company was notified of the drill. Page two, section 3, noted the time the alarm was reset, the time the alarm company was notified of the all clear, if the alarm company received the signal and if the company received the signal for the correct pull station was blank.
Review of the central monitoring system event report revealed the signal was received at 6:26:12 PM for a test.

b. The fire drill dated 02/24/16, conducted at 1800. had no noted time the alarm company was notified of the drill or if a pull station was pulled. Page two, section 3, which noted the time the alarm was reset, the time the alarm company was notified of the all clear, if the alarm company received the signal and if the company received the signal for the correct pull station was blank.

Review of the central monitoring system event report revealed the signal was received at 6:40:01 PM for a test.

c. The fire drill dated 02/25/16, conducted at 8:30 P.M. had no affected area identified, the time the alarm company was notified of the drill or if a pull station was pulled. Page two of the form was missing.

d. The fire drill dated 04/19/16, conducted at 10:54 A.M. had no affected area identified and no time the alarm company was notified of the drill.

e. The fire drill dated 05/16/16, conducted at 7:20 PM had no noted time the alarm company was notified of the drill. Page two, section 3, did not note the time the alarm company received the signal and if the company received the signal for the correct pull station.

Interview of Staff D on 06/15/16 at 3:32 P.M. regarding the documentation of fire drills confirmed the drill information was incorrectly completed with inaccurate information and/or incomplete information.

Based on facility observation, review of facility documentation and staff interview the facility failed to ensure the fire alarm system that is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building, the fire alarm system wiring or other transmission paths were to be monitored for integrity, initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system, manual alarm boxes are provided in the path of egress near each required exit, manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations, occupant notification is provided by audible and visual signals, the fire alarm system transmits the alarm automatically to notify emergency forces in the event of fire, the fire alarm automatically activates required control functions and system records were to be maintained and readily available. This finding potentially could affect all 16 patients.

Findings included:

1. On 06/14/16 at 10:00 A.M., Staff D was interviewed regarding the fire alarm system. Staff D stated the fire alarm system was interconnected with the fire alarm system for the adjoining skilled nursing facility. Staff D stated the maintenance staff of the skilled facility worked with this facility to coordinate fire drills and that information was exchanged regarding the fire drills.

Staff D revealed the facility provided care for patients who required special locking arrangements on exit doors due to their clinical needs. These exit doors were magnetically locked and required staff to have key cards in order to access and leave the facility. Staff D stated the doors were a component of the fire alarm system in that, when activated, the doors were released allowing for exit discharge from the facility. Staff D stated the doors were tested during fire drills to ensure proper release in the event of an actual emergency.

Tour of the facility with Staff D on 06/14/16, revealed that all staff had key cards in their possession in order to enter and leave the facility. A card reader at each exit door released the door when the card was recognized. Observation of an exit from the common area near the nursing station lead to an enclosed courtyard. A gate, designated as an exit, lead to the public way from the courtyard, was also equipped with the magnetic lock. Staff D confirmed the gate also released with activation of the fire alarm system. Staff D stated that during fire drills, when the alarm was activated, staff are posted at exit doors to ensure that patients do not elope.

Review of documented fire drills revealed no evidence of testing for release of the magnetic locks on the exit doors. On 06/15/16 at 9:00 A.M. Staff D confirmed there was no documentation to confirm testing for release of the exit doors.

2. On 06/14/16 review of documented fire drills conducted since December 2015 was completed. The facility documentation included sections of the fire drill that were to be evaluated. Page one of the documented included the time the alarm company was notified of the drill and the area affected for the drill/fire. Section two, of page one, included an area to document what time pull station was pulled. Section 3, page two of the fire drill report, was labeled the "All Clear". This section was to note the time the alarm was reset and the time the alarm company was notified of the all clear. Items 4 and 5 of the section were to note if the alarm company received the signal and if the company received the signal for the correct pull station.

Review of the eight fire drills documented between December 2015 and April 19, 2016 revealed that five of eight drills did not contain completed information. The following five fire drills lacked completed documentation as follows:

a. The fire drill dated 02/08/16, conducted at 5:30 P.M. had no noted time the alarm company was notified of the drill. Page two, section 3, which noted the time the alarm was reset, the time the alarm company was notified of the all clear, if the alarm company received the signal and if the company received the signal for the correct pull station was blank.

Review of the central monitoring system event report revealed the signal was received at 6:26:12 PM for a test.

b. The fire drill dated 02/24/16, conducted at 6:00 PM had no noted time the alarm company was notified of the drill or if a pull station was pulled. Page two, section 3, which noted the time the alarm was reset, the time the alarm company was notified of the all clear, if the alarm company received the signal and if the company received the signal for the correct pull station was blank.

Review of the central monitoring system event report revealed the signal was received at 6:40:01 PM for a test.

c. The fire drill dated 02/25/16, conducted at 8:30 P.M. had no affected area identified, the time the alarm company was notified of the drill or if a pull station was pulled. Page two of the form was missing.

d. The fire drill dated 04/19/16, conducted at 10:54 A.M. had no affected area identified and no time the alarm company was notified of the drill.

e. The fire drill dated 05/16/16, conducted at 1920 had no noted time the alarm company was notified of the drill. Page two, section 3, did not note the time the alarm company received the signal and if the company received the signal for the correct pull station.

Interview of Staff D on 06/15/16 at 3:32 P.M. regarding the documentation of fire drills confirmed the drill information was incorrectly completed with inaccurate information and/or incomplete information.