Failure to Maintain and Communicate Emergency Evacuation Plan Amid Inoperable Sprinkler System
Penalty
Summary
The facility failed to maintain a written plan for the protection and evacuation of all residents in the event of an emergency, as required by regulatory standards. During a record review, it was found that the annual dry sprinkler inspection revealed the attic dry system was capped, leaving only six sprinkler heads active, and the system failed inspection. At the time of the survey, both a CNA and the ADON were unaware that a portion of the sprinkler system was not operational and not functioning as designed and installed. No education or instruction was provided to staff regarding how their response to a fire should change given the inoperable sprinkler system. This finding was confirmed by the Maintenance Director during the survey. No information was provided regarding any specific residents' medical history or condition at the time of the deficiency.
Plan Of Correction
1. The facility failed to adequately communicate to staff that the dry sprinkler system was not functioning properly throughout the building and did not clearly define emergency evacuation procedures in the event of system failure. 2. Lack of communication regarding system malfunction and absence of defined evacuation procedures could place all residents, staff, and visitors at risk during a fire emergency. 3. Corrective actions taken include: - All facility staff were immediately notified that the dry sprinkler system was not functioning and responded appropriately by initiating fire watch procedures. - The Fire Watch policy has been revised to include specific evacuation protocols. The updated policy now requires immediate evacuation of the affected fire/smoke compartment upon any detection of smoke or fire. - The Maintenance Director was educated on the importance of prompt and clear communication to all staff regarding emergency system failures. - All staff have been re-educated on the updated Fire Watch policy and the emergency evacuation procedures. 4. The Maintenance Director is responsible for timely communication of any emergency system failures to facility staff and will report compliance and communication actions to the Quality Assurance (QA) Committee.