The Orchard Nursing and Rehabilitation Centre
Deficiency Details, Certification Survey, October 12, 2010
Regional Office: Capital District Regional Office
K50 NFPA 101: FIRE DRILLS
Severity: Potential for more than Minimal Harm
Corrected Date: December 1, 2010
Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9 PM and 6 AM a coded announcement may be used instead of audible alarms. 220.127.116.11
Citation date: October 12, 2010
Based on staff interview and record review, it was determined that the staff were not familiar with the facility's fire response policy, during the standard recertification survey. 2000 NFPA 101 Life Safety Code section 18.104.22.168 requires that the basic response to fire shall include confinement of the effects of fire by closing doors to isolate the fire area. Specifically, 4 of 7 staff interviewed did not state they would close the door to the fire area, after evacuation of the room as part of the basic response to fire. This resulted in no actual harm with the potential for more than minimal harm that was not immediate jeopardy. This was evidenced as follows:
Interviewed on 01/12/2010, one certified nurse assistant at 9:45 am, one occupational therapist at 10:15 am, one dietary aide at 10:20 am, and one activity aide at 10:30 am and they did not know to close the door to the fire area after evacuation of the room.
Record review of the facility's emergency fire procedure on 10/12/2010 revealed that staff persons are to close doors to prevent fire and smoke from spreading.
2000 NFPA 101 22.214.171.124; 1997 NFPA 101 13-7.2.1; 10 NYCRR 415.29, 711.2(a)(1)