HospitalInspections.org

Based fire drill documentation review and interview, it could not be determined a quarterly fire drill was performed on the second shift for the years 2011 and 2012 due to a lack of documentation available for review. 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 and 25 of 25 patients on 10/15/12. The findings follow:

A. Review of the fire drill documentation provided on 10/15/12 at 1030 revealed there was no evaluation of the second shift participation in fire drills for the years 2011 and 2012.
B. In an interview conducted on 10/15/12 at 1045, the Safety Officer verified there was no further fire drill documentation was available for review.