HospitalInspections.org

Based upon records review and interview, the facility failed to ensure that fire drills includes the transmission of a fire alarm signal, simulation of emergency fire conditions, are held at unexpected times under varying circumstances, and conducted at least quarterly on each shift as required by 19.7.1.4 through 19.7.1.7. This deficient practice could affect all occupants occupants in the event of staff not properly trained in an emergency.

Findings Include:
On 06/04/19 at approximately 10:25 AM while conducting document review the facility was not able to provide documentation of a fire drill for the 2nd shift, 4th quarter of 2018. This was confirmed with Staff #1 at the time of review.