Inconsistency in Fire and Evacuation Procedures
Summary
The facility's fire and evacuation policies and procedures were found to be inconsistent with the actual practices during a Life Safety Code survey. The documented Fire Plan Policy required the use of red circular magnets to mark evacuated rooms, but observations revealed the absence of these magnets in resident rooms. Instead, orange and yellow plastic tags were found in fire extinguisher cabinets, which were used to identify fire rooms and evacuated rooms, respectively. Interviews with the Administrator and Maintenance Director confirmed the use of these tags, but they were unaware of the red magnets mentioned in the policy. Further interviews with the Infection Preventionist, who had been assisting with new employee orientations, revealed a lack of documentation and education regarding the use of room marking tags. The Infection Preventionist was not provided with any materials about the marking system and verbally instructed staff based on the available tags. Fire Drill Reports from earlier in the year indicated that knowledge of room tags was part of the observations, yet the facility's current practice did not align with the documented procedures, leading to the deficiency.
Plan Of Correction
Plan of Correction: Approved December 31, 2024 1. A review of the fire/evacuation policy and procedure was conducted by Administrator on 12/31/2024. The Policy and procedure was updated for fire and evacuation during potential fire. 2. All residents are at risk for policies and procedures for fire evacuation not matching the actual procedures. 3. RN Educator will educate all staff on the new policy and procedure for fire and evacuation practices. 4. A mock drill was conducted on fire and evacuation procedures. The drill was discussed at QAPI and any deficient practices were reeducated. 5. The facility will audit all fire drills conducted monthly. Any deficient practices will be addressed and brought to QAPI for further review. Person Responsible: Maintenance Director
Penalty
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