Failure to Conduct Required Fire Drills
Summary
The deficiency identified during the Life Safety Code survey was the failure to conduct fire drills at least once per shift per quarter, as required by the facility's Fire Drill Policy. The policy, approved in June 2023, mandates that fire drills be scheduled by the Director of Maintenance, Nurse Educator, or a designee to ensure staff preparedness in the event of a fire. However, a review of fire drill reports revealed that only two fire drills were conducted during the second quarter of 2023 and two during the third quarter of 2024, failing to meet the requirement of one drill per shift per quarter. Interviews with facility staff, including the Director of Facilities Maintenance and the Registered Nurse Infection Preventionist Nurse Educator, highlighted issues in the scheduling and documentation of fire drills. The Maintenance staff was primarily responsible for planning the drills, but it was sometimes a joint effort with the Education staff. The Administrator confirmed that the Maintenance Director was responsible for maintaining fire drill documentation, but the individual in that role during 2023 and 2024 was no longer employed at the facility, contributing to the lack of proper documentation and execution of the required fire drills.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 Corrective action for the deficient practice is to conduct monthly fire drills as required. The Director of Maintenance and Nursing Educator will be educated on the requirements for completion on each shift (days, evening, nights) every quarter. An audit will be conducted on a monthly basis for completion of that month’s drill, verification that drill was during proper shift, and the next month’s drill shift is planned. Ongoing compliance will be monitored by the Director of Maintenance and logged in the TELS system. The results of the audit will be reported to the QA committee, for both the current and following month for continued compliance. The Administrator will provide the education and review Policy and Procedure with staff. Maintenance Director will perform Monthly Audits and Drills Presented in QA for 3 months. Responsible Designee - Maintenance Director
Penalty
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