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Based on observation, interview, and policy review, the provider failed to ensure staff were familiar with the provider's fire drill procedures for a patient room regarding:
*Isolating the fire.
*Activating the fire alarm.
*Removing patients from adjacent rooms. Findings include:

1. Observation on 7/24/18 at 1:25 p.m. revealed the staff member responding to the simulated fire in patient room 108 did the following:
*Entered the room.
*Located the fire in the bathroom.
*Talked with the patient in the wheelchair (played by a maintenance mechanic) for approximately twenty seconds.
*Exited the room with the patient.
*Did not close the patient's room door.
*Did not activate the fire alarm.
*Did not evacuate the other patients and others to the opposite side of the nearest fire door.

As the staff member attended to the patient in the room a nurse called to a staff person at the nurses desk to tell her there was a fire in room 108. No other staff assisted the initial staff person with closing doors, removing patients in adjacent rooms, or activating the fire alarm.

During the process of responding to the simulated fire staff members gathered around the nurses station until the location was announced overhead approximately one minute later. The fire alarm was not sounded until approximately two minutes after the fire had been located.

Interview with the maintenance mechanic at the time of the above observations confirmed those findings.

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

Review of the February 2015 Condition Red policy revealed:
"Guidelines: In the event that smoke, fire, sparks or explosion are detected but the fire alarm system is to activated, you must locate the nearest fire pull station and activate the alarm immediately."
"Procedure:
R-Remove persons in immediate danger
A-Alarm
*Pull the nearest alarm box.
*Call extension #720, announce Attention Attention Condition RED, give location.
C-Contained fire-Close all doors and windows to the areas.
E-Extinguish fire-Retrieve nearest extinguisher and fight fire."

Evacuate Patients and other to the opposite side of the nearest fire doors form the immediate fire area.