Failure to Conduct and Document Required Quarterly Fire Drills
Penalty
Summary
The facility failed to ensure that fire drills were conducted quarterly on each shift as required by NFPA 101 standards. Document review revealed that six out of twelve required fire drills were not documented as completed, specifically missing drills for the 1st quarter on the 1st and 2nd shifts, the 2nd quarter on the 2nd shift, the 3rd quarter on the 1st and 2nd shifts, and the 4th quarter on the 3rd shift. During an exit interview, both the Administrator and Maintenance Director confirmed the absence of documentation for these fire drills. 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
Maintenance director completed all first, second, and third shift fire drills to be in compliance. Maintenance director reeducated by NHA/Designee on K0712 with focus on completing monthly fire drills, logging drills, and placing in life safety binder as per regulation. Maintenance director/designee to audit monthly x 4 to ensure that fire drills are completed and logged into life safety binder. Results of audits to be reviewed at QAA committee monthly to determine the need for further follow-up/monitoring.