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VANDERBILT UNIVERSITY MEDICAL CENTER
Evacuation and Relocation Plan
Tag No.: K0711
Based on document review and interview, the facility failed to follow the procedures in case of fire.
The findings included:
Interview with staff member #1 on 08/19/2024 at 12:41 PM, revealed the facility experienced a fire in patient room 10627 and the building's fire alarm was not activated.
Document review of unit specific fire response plan (Department Disaster Response Sub-Plan Department 10CCT) state "Persons discovering the fire.... 2. Activate nearest fire alarm pull station."
Interview with staff member #3 on 08/20/2024, revealed the staff member responded to room 10627 and discovered smoke in the room. Further interview revealed the staff member evacuated the room and called the on-call Administrative Coordinator and Facilities Management to report the fire.
NFPA 101 19.7.2.1.2 (2012 Edition)
The Senior Director Accreditation and Standards acknowledged this finding during the telephone exit conference on 08/26/2024.