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MERCY MCCUNE BROOKS HOSPITAL
No Description Available
Tag No.: K0050
Based on document review and interview the facility failed to conduct fire drills for each shift on at least a quarterly basis. This deficient practice affects all occupants of the building. The facility census was 19.
Findings included:
1. Review of the facility fire drill records, conducted on the afternoon of 01/08/13, showed only two fire drills were documented, one on January 24, 2012 and another on February 29, 2012, for the 7:00 PM to 7:00 AM shift during 2012.
2. During an interview on 01/09/13 at 2:33 PM, Staff X, Maintenance Manager, stated not all fire drill occurring in 2012 were documented.
Section 18.7.1.2 of the National Fire Protection Association (NFPA 101) states 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. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.