HospitalInspections.org

Based on a review of documentation and interviews it was determined the facility failed to assure the safety of patient in non-medical emergencies as evidence by not performing monthly fire drills and simulating evacuation of patients during fire drills.

Findings were:

A review of fire drill documentation for the time period of 8-1-2010 through 7-31-2011, revealed that only 4 fire drills were performed during this time period. The 4 documented fire drills reviewed gave no indication that the evacuation of patients was simulated during the drills. An interview with the Director of Nursing on 8-17-11, he confirmed that evacuation of patients was not simulated during the drills.

The above was confirmed in an interview with the Administrator and the Director of Nursing in the facility conference room on the afternoon of 8-18-11.