HospitalInspections.org

Based on Fire Drill Documentation review and interview, it could not be determined the facility participated in fire drills as required. Failure to conduct fire drills had the potential to affect patient safety from fire because proper fire response training was not tested and evaluated. The failed practice had the potential to affect to all patients admitted to the facility and 16 of 16 patients on 11/15/10. The findings follow:

A. Review of the Fire Drill documentation provided on 11/15/10 at 1400 revealed for the year 2009 documentation was for the separately owned and operated geriatric psychiatric unit located on the same floor of the building. There was no documentation of participation by the facility in any of the documented fire drills available for review.
B. In an interview on 11/17/10 at 1000, the Director of Human Resources verified there was no further fire drill documentation available for review.

Based on Generator Log Review and interview, it was determined weekly inspections of the emergency generator were not conducted beginning in March 2010 to 11/15/10. Failure to conduct weekly inspections of the generator prevents the facility from ensuring the reliability of the generator for continuation of life support and fire safety equipment in the event of the loss of normal power. The failed practice had the potential to affect to all patients admitted to the facility and 16 of 16 patients on the first day (11/15/10) of the survey.

A. Review of the Weekly Emergency Generator Log on 11/15/10 at 1500 revealed weekly inspections of the generator had not been documented beginning in March 2010 to the present.
B. In an interview on 11/15/10 at 1520, the Safety Officer verified there was no further documentation available for review.