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Based on record review and interview, the facility failed to document and hold fire drills under varied conditions at different times of the day for three of four quarters reviewed. This deficient practice had the potential to affect staff preparation and experience in providing for the protection of all patients in the event of a fire.

Findings are:

Record review on 01-19-16 at 10:35 AM of fire drill documentation showed that the night shift did not have a 4th Quarter Drill and the night shift 3rd quarter fire drill was within one hour of the previous one.

Interview at 10:35 am on 01-19-16 with Maintenance " A " confirmed the observations and findings.


Record review of the following NFPA Standard revealed: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 18/19.7.1.2