HospitalInspections.org

Based on document review and interview the facility failed to conduct fire drills at various times during the day for all three shifts. This deficient practice has the potential to affect all occupants in the facility during an emergency situation. The facility census was 12.

Findings included:

Review of the fire drill records for the previous 12 months, conducted on the morning of 10/25/16, showed, four of four fire drills conducted on each shift occurred within the same hour of the day.

Fire drills for the 1st shift occurred during the following times:
10/28/15 at 10:26 AM
01/28/16 at 10:00 AM
04/22/16 at 09:45 AM
07/06/16 at 09:50 AM

Fire drills for the 2nd shift occurred during the following times:
11/24/15 at 03:30 PM
02/22/16 at 03:05 PM
05/25/16 at 04:00 PM
08/23/16 at 03:15 PM

Fire drills for the 3rd shift occurred during the following times:
12/24/15 at 11:30 PM
03/22/16 at 11:35 PM
06/27/16 at 11:00 PM
09/09/16 at 11:00 PM

During an interview on 10/25/16 at 2:44 PM, Staff DD, Director of Plant Operations, confirmed the fire drills on all three shifts had been conducted during the same time period of day.

Section 4.7.5 of the National Fire Protection Association (NFPA 101) states drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

Based on document review and interview the facility failed to perform an annual inspection of the facility fire alarm system. This deficient practice affects all occupants of the building. The facility census was 12.

Findings included:

Review of the facility fire alarm system inspection reports, conducted on the morning of 10/25/16, showed the fire alarm system had not been inspected and certified by an outside contractor since September, 25, 2015.

During an interview on 10/25/16 at 2:43 PM, Staff DD, Director of Plant Operations, confirmed the fire alarm system had not been inspected and certified since September of 2015.

Section 9.6.1.7 of the National Fire Protection Association (NFPA 101) states to ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

Based on document review and interview the facility failed to conduct fire drills at various times during the day for all three shifts. This deficient practice has the potential to affect all occupants in the facility during an emergency situation. The facility census was 12.

Findings included:

Review of the fire drill records for the previous 12 months, conducted on the morning of 10/25/16, showed, four of four fire drills conducted on each shift occurred within the same hour of the day.

Fire drills for the 1st shift occurred during the following times:
10/28/15 at 10:26 AM
01/28/16 at 10:00 AM
04/22/16 at 09:45 AM
07/06/16 at 09:50 AM

Fire drills for the 2nd shift occurred during the following times:
11/24/15 at 03:30 PM
02/22/16 at 03:05 PM
05/25/16 at 04:00 PM
08/23/16 at 03:15 PM

Fire drills for the 3rd shift occurred during the following times:
12/24/15 at 11:30 PM
03/22/16 at 11:35 PM
06/27/16 at 11:00 PM
09/09/16 at 11:00 PM

During an interview on 10/25/16 at 2:44 PM, Staff DD, Director of Plant Operations, confirmed the fire drills on all three shifts had been conducted during the same time period of day.

Section 4.7.5 of the National Fire Protection Association (NFPA 101) states drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

Based on document review and interview the facility failed to perform an annual inspection of the facility fire alarm system. This deficient practice affects all occupants of the building. The facility census was 12.

Findings included:

Review of the facility fire alarm system inspection reports, conducted on the morning of 10/25/16, showed the fire alarm system had not been inspected and certified by an outside contractor since September, 25, 2015.

During an interview on 10/25/16 at 2:43 PM, Staff DD, Director of Plant Operations, confirmed the fire alarm system had not been inspected and certified since September of 2015.

Section 9.6.1.7 of the National Fire Protection Association (NFPA 101) states to ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.