Lack of Fire Watch Policy During Fire Alarm System Outage
Penalty
Summary
The facility failed to maintain a full and accurate fire watch policy for situations when the fire alarm system is out of service for more than four hours, as required by NFPA 101. During a document review, it was found that there was no fire watch policy in place to address the impairment or outage of the fire alarm system for extended periods. This deficiency was confirmed during interviews with the Director of Nursing and the Director of Maintenance, who acknowledged the absence of such a policy. The lack of a fire watch policy affected the entire component of the fire alarm system and was identified through both documentation review and staff interviews. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
The facility has a Fire Watch Policy that is available for review. The Fire Watch Policy will be placed in the Safety and Disaster Policy & Procedure Manual. The Environmental Services Director will be educated on the Fire Watch Policy. The Safety and Disaster Policy & Procedure Manual will be reviewed yearly, every July.