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ED FRASER MEMORIAL HOSPITAL
No Description Available
Tag No.: K0050
Based on records review, the facility failed to provide evidence of fire drills being conducted at unexpected times under various conditions at least once per shift per quarter which can lead to failure of facility staff to perform properly during emergency events which can lead to injury or loss of patients, staff, or other building occupants.
The findings include:
On May 30, 2013 at 9:00 AM to 12:00 PM during records review with facility staff, the facility fire drill records showed that the drills for the 1st shift, 7 AM-3 PM, were not being conducted at unexpected times as the drills held for the first quarter of 2013 were conducted on 1/31/2013 at 10:50 AM. Drill for the 2nd quarter of 2012 was on 4/30/2013 at 10:45 AM with the drill for the 3rd quarter on 7/24/2012 at 10:44 AM. Drill for the 4th quarter of 2012 was on 10/29/2012 at 10:52 AM. The close proximity of the drill times would allow for staff to become familiar with drill times and complacent in duties. Drills shall be held one per shift per quarter at unexpected times under various conditions in accordance with NFPA 101 (2009) 4.7.1, 4.7.2, 4.7.3, 4.7.4, 4.7.5, 4.7.6, 19.7.1.1, 19.7.1.2, 19.7.1.3.
These findings were reconfirmed with the Facility Plant Operations Director during the exit conference May 30, 2013 at 12:15 pm.
LIFE SAFETY CODE STANDARD
Tag No.: K0050
Based on records review, the facility failed to provide evidence of fire drills being conducted at unexpected times under various conditions at least once per shift per quarter which can lead to failure of facility staff to perform properly during emergency events which can lead to injury or loss of patients, staff, or other building occupants.
The findings include:
On May 30, 2013 at 9:00 AM to 12:00 PM during records review with facility staff, the facility fire drill records showed that the drills for the 1st shift, 7 AM-3 PM, were not being conducted at unexpected times as the drills held for the first quarter of 2013 were conducted on 1/31/2013 at 10:50 AM. Drill for the 2nd quarter of 2012 was on 4/30/2013 at 10:45 AM with the drill for the 3rd quarter on 7/24/2012 at 10:44 AM. Drill for the 4th quarter of 2012 was on 10/29/2012 at 10:52 AM. The close proximity of the drill times would allow for staff to become familiar with drill times and complacent in duties. Drills shall be held one per shift per quarter at unexpected times under various conditions in accordance with NFPA 101 (2009) 4.7.1, 4.7.2, 4.7.3, 4.7.4, 4.7.5, 4.7.6, 19.7.1.1, 19.7.1.2, 19.7.1.3.
These findings were reconfirmed with the Facility Plant Operations Director during the exit conference May 30, 2013 at 12:15 pm.