HospitalInspections.org

Based on record review and interview, the provider failed to ensure fire drill procedures were conducted quarterly for the required shifts (for the third shift quarter four and for the second shift first and second quarters). Findings include:

1. Record review on 2/11/20 at 2:45 p.m. revealed there was no documentation of third shift fire drills for quarter four (October, November, December) 2019. There was no documentation of second shift fire drills for the first quarter (January, February, March) or the second quarter (April, May, June) 2019.

Interview with the facilities manager at the time of the record review confirmed those findings. He thought his mid-day drills would fulfill the requirement for second shift. He was unaware that he had not met the requirement during the third shift for 2019.

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