HospitalInspections.org

Based on fire drill documentation review and interview, it was determined the facility did not conduct two of two required fire drills in the third quarter of 2012 and one of two fire drills in the fourth quarter of 2012. Failure to perform quarterly fire drills on each shift prevented the facility from ensuring staff are trained and prepared to respond to fire emergencies with required procedures in a prompt and orderly manner to protect patients from fire and smoke. The failed practice had the potential to affect all patients, staff and visitors. The facility had a census of 17 patients on 01/22/13. The findings follow:

A. Review of the fire drill documentation 01/23/13 at 0850 revealed there was no documentation of a fire drill for the first or second shift in the third quarter of 2012. There was no documentation of a fire drill for the second shift in the fourth quarter of 2012.
B. In an interview on 01/23/13 at 0915, the Safety Director verified there was no further documentation available for review.