|Survey Date: 7/31/2007|
Regulation Title: EMERGENCY PREP: PERIODIC DRILLS
Regulation Description: All personnel are trained, as part of their employment orientation, in all aspects of preparedness for any emergency or disaster. The emergency preparedness plan provides for orientation and regular training and periodic drills for all personnel in all procedures so that each person promptly and correctly carries out a specific role in case of an emergency.
Based on record review and staff interview, the facility failed to conduct periodic fire drills for facility personnel and patients. Furthermore, the facility failed to have a policy and procedure developed regarding conducting fire drills with facility staff and patients. The findings were:
During the entrance conference on 7/30/07, a log of fire drills was requested for review during the recertification survey. However, there was no documentation available regarding fire drills having been performed.
The director of nursing (DON) was interviewed on 7/30/07 at 2:00 p.m. The DON stated that fire drills had not been conducted for several years, and furthermore, could not find documentation actual drills had ever been done. The DON further stated the facility would be implementing a policy and procedure immediately as well as doing quarterly drills.
In summary, the failure to conduct periodic fire drills increased the potential for unpreparedness of staff to assist patients in the case of a real fire.
Facility Plan of Correction:
All Summit Kidney Center dialysis employees have attended a current Fire Safety lecture and training provided by the CSFD on 8/21/07. Items covered were 911 situations, violence/bomb policies, weather conditions,hazardous material release and basic fire emergencies policies. Each staff member practiced with a fire extinguisher.
Hazmat training has begun to be implemented for all dialysis employees.
To ensure that all employees are informed of emergency preparedness procedures, quarterly in-services and training will be provided.
The in-services will be provided by various sources: medical companies, city agencies, and medical professionals, etc.. . The DON will be responsible to assure the training will occur.
Quarterly In-services/training will be noted in QA manual for each employee.