Fire Drill Documentation Deficiency
Summary
The facility failed to ensure that fire drill written records included the specific emergency fire conditions simulated during each drill, as required by NFPA 101: Life Safety Code. This deficiency was identified during a review of fire drill records from August 17, 2024, to January 15, 2025, where it was noted that six out of twelve fire drills did not document the scenario that caused the simulated fire drill and fire alarm activation. The reports merely noted that a 'Code red' was called, all rooms were closed, and there was a good response from staff, without detailing the specific scenario played. This omission made it impossible to verify that the drills were conducted under varying conditions, as required by the code. The Director of Building Services acknowledged this oversight and indicated that scenarios would be added to future fire drills.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 I. The facility immediately added the scenario simulated to the Fire Drill Report for all fire drills going forward. II. Anyone has the potential to be affected. III. The maintenance director was educated on 2012 NFPA 101:4.7.4 on 2/12/25 by the Corporate Director of Maintenance. IV. The facility created an audit tool to ensure fire drills include a simulated scenario when conducted. Audits will be conducted by the Director of Maintenance monthly for 12 months. All findings will be reported on QAPI. V. Responsible party: Director of Maintenance/ Designee.
Penalty
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