Deficient Emergency Preparedness Policies and Procedures
Penalty
Summary
The facility failed to develop and implement emergency preparedness policies and procedures in accordance with regulatory requirements. Specifically, the emergency plan, risk assessment, and communication plan were not fully integrated into the facility's policies and procedures, and the required annual review and update of these documents was not completed. During record review, it was found that the policy for emergency situations involving electrical power outages directed staff to use an 'emergency kit' cart located in the 500 Hall. However, field verification revealed that there was no emergency kit cart in the 500 wing, as it had been moved to the 600 service hall without updating the policy or informing staff of the new location. Additionally, the facility's severe weather policy stated that staff would monitor a weather radio located at the main nurse station. Upon field verification, it was discovered that there was no weather radio at the main nurse station, contrary to what the policy indicated. These discrepancies were confirmed through an interview with the maintenance director at the time of record review. The lack of alignment between the facility's written policies and the actual resources and equipment available could affect all occupants in the event of an emergency.