Failure to Conduct Quarterly Fire Drills
Penalty
Summary
The facility failed to conduct fire drills at least quarterly per shift, as required by NFPA 101 Life Safety Code (2012 Edition), Section 19.7.1. This deficiency was identified through a review of the facility's "Fire Drill Reports," which showed no documented evidence of fire drills being conducted for April 2024 and May 2024. During an interview, a staff member confirmed the absence of fire drill reports for these months. This failure had the potential to affect all 74 residents in the facility.
Plan Of Correction
1. Corrective Action of Areas Affected: The facility cannot retroactively correct the identified concern related to the previous April and May fire drills not being completed. 2. Other Areas Affected: All residents have the potential to be affected by this deficient practice. The Administrator and Director of Maintenance ensure that all fire drills are completed monthly on a shift rotating basis including weekend requirement. 3. Systemic Changes to Prevent Future Occurrences: The Administrator reviews compliance with fire drill requirements prior to the end of each month to ensure the rotating schedule is followed.