Failure to Activate Fire Alarm During Electrical Fire
Penalty
Summary
The facility failed to follow its own Fire Policy during an incident in which the main electrical panel room's switchboard caught fire. When smoke was discovered, staff members responded by calling 911 and notifying other staff, but did not activate the manual fire alarm system. The fire alarm did not trigger automatically, and no one pulled the nearest manual fire alarm, which was located near the exit doors by Resident Room 17 and the Director of Staff Development's office. This omission was confirmed through interviews with the Director of Staff Development and the Maintenance Supervisor, as well as direct observation of the location of the manual pull station. A review of the facility's Fire Policy indicated that staff are required to alert others over the intercom and pull the nearest fire alarm in the event of a fire. Despite this clear directive, staff did not follow the procedure, resulting in a failure to alert all individuals in the facility during the fire event. The deficiency was identified through interviews, record review, and observation, and it affected the safety of all 49 residents, staff, and visitors present at the time.
Plan Of Correction
K 0711 Corrective action for residents found to have been affected by this deficiency: On 07/28/2025, the Administrator provided a 1:1 in-service to the Director of Staff Development (DSD) and to Housekeeping 1 (HSK 1) on the Facility's Fire Policy and Procedure; and course of action for all personnel to follow in the event of a fire, including pulling the nearest fire alarm. Corrective action for residents that may be affected by this deficiency: On 07/27/2025, 07/28/2025, and 08/03/2025, the DSD provided an in-service to department heads, nurses, dietary, activity, housekeeping/laundry, maintenance, and other staff on the Facility's Fire Policy and Procedure and course of action for all personnel to follow in the event of a fire, including pulling the nearest fire alarm. Measures that will be put into place to ensure that this deficiency does not recur: During daily rounds, the DSD will randomly ask staff members on all shifts what to do in case of fire to ensure pulling the fire alarm is identified. Discussion on activating the fire alarm will be part of the monthly fire drills performed by the facility's Fire Life Safety & Security vendor. During the initial orientation, the DSD will ensure new hires will be familiar with the facility's Fire Policy and Procedure, including pulling the fire alarm. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: The QAPI Risk Management Practices Subcommittee will use the indicator, "Fire Drill Program," monthly, to ensure staff