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Based on record review and interview, it was determined the facility failed to ensure fire drills were conducted, according to National Fire Protection Association (NFPA) standards.



The findings include:



Record review of the facility fire alarm records on 02/22/2017 at 2:09 PM, with the Safety Officer, revealed the facility conducted fire drills for each shift every six (6) months. Interview, with the Safety Officer during record review, revealed he had conducted the fire drills to a previous standard and was not aware he had conducted the fire drills incorrectly.



Reference: NFPA 101 (2012)

19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.