HospitalInspections.org

Based on the review of 13 of 16 personnel records (Records #E1, E3, E4, E5, E6, E7, E8, E10, E11, E12, E13, E14, and E15) and an interview with E15, it was determined the facility failed to maintain documentation of training staff in handling emergencies and evacuation of patients, personnel and guests, and cooperation with disaster authorities per regulation.

Findings include:

Based on the review of 16 employee records it was revealed that 13 of 16 employees(Records #E1, E3, E4, E5, E6, E7, E8, E10, E11, E12, E13, E14, and E15) lacked documentation in the mandatory annual disaster program. In an interview with E15 on 5/24/11 at 0950, it was determined that there was no documentation of the facility's participation in a regional drill that was conducted approximately 6 months earlier. E15 stated that the facility has participated in numerous annual disaster drills but he/she also stated that evaluations of the drills were not documented. E15 also confirmed there were no minutes of the Emergency Preparedness Committee.