HospitalInspections.org

Based on record review and interview, the facility failed to follow their fire plan procedures.

The findings include:

Record review and interview with the operations manager on 4/13/15 revealed the facility did not follow their fire plan. On 4/13/15 a rooftop HVAC unit shorted out and started smoking causing some smoke to filter back into the facility. The facility's fire plan states that the person in charge of the command center, in consultation with the Safety Officer/designee shall make all evacuation decisions. The facility did not follow the chain of command and consult with the required people for an evacuation of patients. The Medical Director of Respiratory Care & Chief of Staff initiated the evacuation of the patients without consulting with the person in charge of the command center who makes the determination for evacuation if needed.

This finding was verified by the maintenance director and acknowledged by the administrator during the exit conference on 5/22/15.