Failure to Conduct Required Fire Drills
Penalty
Summary
The facility failed to conduct the required number of fire drills, as mandated by NFPA 101, which requires fire drills to be held at least quarterly on each shift. Upon review of the documentation on January 8, 2025, it was found that the facility did not have records for five out of the twelve required fire drills over the past year. Specifically, there was no documentation for the first and third shifts during the second quarter, the second shift during the third quarter, and the first and third shifts during the fourth quarter. An interview with the Facility Administrator and Maintenance Director confirmed the absence of documentation for these fire drills. This deficiency affects the entire facility, as the drills are essential for ensuring staff familiarity with emergency procedures and maintaining safety standards. The lack of documentation indicates that the facility did not meet the regulatory requirements for fire safety preparedness.
Plan Of Correction
An audit of fire drills at Longwood Skilled Nursing noted 12 fire drills in 2024. However, there was one night shift in the second quarter, one evening shift in the third quarter, and a night shift drill in the fourth quarter that were missed. The maintenance manager will create a quarterly fire drill schedule to ensure each shift is covered every quarter. There were no identified issues related to the deficient practice of the missed fire drills. The maintenance manager educated the maintenance team on the need to conduct drills on every shift and every quarter. Completed drills will be submitted to the QAPI team prior to the end of the quarter to ensure that all shifts participated in a fire drill during the quarter. Any missed drills will be completed by the maintenance team before the end of the quarter. Documentation reports from the monthly drills will be presented at the QAPI meeting to identify and address any issues of non-compliance.