HospitalInspections.org

Based on a review of available documentation and interviews, the facility failed to ensure that the all hazard disaster preparedness plan was exercised at least annually and fire drills were were conducted 12 times per year, one drill per shift per quarter.

Findings were:

A review of a documentation revealed that the facility disaster plan had not be exercised at least annually. The last documented disaster preparedness drill occurred on 12/09/11.

The facility was only able to provide documentation of 4 fire drills performed in the past year: 01/31/12, 03/28/12, 08/28/12, and 10/30/12.

Simulated evacuation of patients and use of firefighting equipment was not included in the documentation of the completed fire drills.

In an interview on 03/20/13, the facility Administrator and Director of Nursing, confirmed that fire drills had not been performed 12 times a year, one drill per shift per quarter. The Director of Nursing also confirmed there had been no disaster drill performed in the past calendar year.