Failure to Conduct and Document Required Fire Drills
Penalty
Summary
The facility failed to conduct required quarterly fire drills for each shift, as evidenced by missing documentation for specific shifts and quarters. During a record review and interview with the Director of Subacute and Plant Operations Manager, it was found that there were no records of a fire drill for the AM shift in the first quarter and third quarter, nor for the PM shift in the fourth quarter. The Plant Operations Manager stated that fire drills were performed quarterly per shift in various departments, but some fire drill reports did not record subacute staff responses. This deficiency affected all 59 residents in the facility.
Plan Of Correction
The director of plant operations updated the current fire drill matrix to reflect a separate Subacute fire drills that will occur monthly for each shift (Main Building and Annex). The director of plant operations provided in-service to the plant operation staff for the new process with the updated fire matrix. (Please see the attachments). MONITORING: 1. The Plant Operations Manager or qualified designee will be inspecting the fire drill record and fire drill process on a quarterly basis. Findings and data collected are reported to the environment of care committee on a quarterly basis for further review and recommendations.