Observations
Based on a review of the fire drill record log, the facility failed to document one monthly fire drill.
The findings include:
The fire drill record log was reviewed on March 1, 2010. The log was reviewed for the period from February 2009 to February 2010. There was no documentation that a fire drill was conducted for June 2009. This was confirmed by the facility director during an interview on March 1, 2010 at 1:00 PM.
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Plan of Correction
The front desk supervisor was notified of this insufficiency and front desk staff were met with to be reminded of the regulations regarding monthly fire drills. To ensure future compliance the front desk supervisor will review the documentation of the monthly fire drills before the end of each month. |