Lack of Fire Watch Policy for Sprinkler System Outage
Penalty
Summary
The facility failed to maintain a complete and accurate fire watch policy for situations when the sprinkler system is impaired or out of service for more than ten hours. During a document review, it was found that there was no policy in place addressing the procedures to follow in the event of a sprinkler system impairment or extended outage. This deficiency was confirmed during an interview with the Director of Nursing and the Director of Maintenance, who acknowledged the absence of such a policy. No information was provided regarding specific residents or their medical conditions in relation to this deficiency.
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.