HospitalInspections.org

Based on record review and staff interview, the facility is not conducting fire drills as required quarterly on each shift and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting 25 patients and all occupants is 4 smoke zones on 2 floors. The facility has a capacity of 25 with a census of 4.

During the tour conducted on 5/27/2016, between 10:30 am and 2 pm, the following is observed:

1.) At approximately 11:20 am it is discovered that there is no documentation of a fire drill being performed for any shift during the 1st quarter of 2016.

2.) At approximately 11:20 am it is discovered that there is no documentation of a fire drills being performed for the 7pm-7am shift during the 3rd and 4th quarter of 2015.

3.) At approximately 11:20 am it is discovered that there is no documentation of a fire drill being performed during the 2nd quarter of 2015.

Maintenance Staff A was present and acknowledged the findings.

NFPA Standard: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. 2000 NFPA 101, 19.7.1.2.