Missing Fire Drill Documentation for Night Shift
Penalty
Summary
The facility failed to maintain complete fire drill records as required by NFPA 101, Life Safety Code, 2012 Edition. During a record review and interview with the Maintenance Director, it was found that one of twelve required fire drills was not conducted. Specifically, the facility did not provide documentation for the night shift (NOC) fire drill during the fourth quarter of 2024. The Maintenance Director was unable to produce the missing record at the time of the survey and indicated that he would need to consult with the Administrator to determine if the records had been sent. The surveyors gave the facility an opportunity to submit the missing fire drill documentation by email, but no records were received by the specified deadline. This deficiency affected all 120 residents across four smoke compartments, as the absence of the required fire drill could impact staff familiarity with emergency procedures. The report does not mention any specific residents' medical histories or conditions at the time of the deficiency.
Plan Of Correction
K712-Fire Drills 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/07/2025, a fire drill was conducted on the NOC shift, which had previously been missed during Q4 of 2024. Documentation was completed and added to the fire drill log. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected by inadequate staff response during an emergency if drills are not routinely conducted on all shifts. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: A fire drill schedule was implemented with quarterly drills planned for all three shifts (day, evening, night). On (date) the Maintenance Director was educated by the Administrator on the requirements and documentation for Fire Drills. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will complete a monthly review of fire drill documentation to ensure each shift completes a fire drill every quarter. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved.