HospitalInspections.org

Based on observation and staff interview, the facility failed to provide documentation that the fire alarm system was connected to a central receiving station. This deficient practice had the potential to delay or prevent fire department notification in the event of an emergency.

Finding are:
Observation and staff interview on 2-7-2024 at 10:45 AM revealed the following:

During record review no central receiving station logs were provided.

During interview on 2-7-2024 at 10:45 AM, Administrative Staff A and Maintenance Staff B confirmed no central receiving station logs were provided.

Based on record review and staff interview, the facility failed to conduct fire drills for each shift. These conditions did not provide simulated training for staff to respond to a fire emergency during various activities and staffing levels.

Findings are:
Record review on 2-7-2024 at 10:00 AM revealed the following:

1. A fire drill was not recorded on the 1st shift of the 2nd quarter of 2023 (April-June)
2. A fire drill was not recorded on the 3rd shift of the 3rd quarter of 2023 (July-Sept.)
3. No fire drills have been recorded for all 3 shifts of the 4th quarter of 2023 (Oct.-Dec.)

During an interview on 2-7-2023 at 10:00 AM Administrative Staff A and Maintenance Staff B confirmed the fire drills had not been conducted.