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VANDERBILT UNIVERSITY MEDICAL CENTER
Fire Alarm System - Notification
Tag No.: K0343
NFPA 101 2012 Edition
39.3.4.3 Occupant Notification.
During all times that the building is occupied (see 7.2.1.1.3), the required fire alarm system, once initiated, shall perform one of the following functions:
" (1)
It shall activate a general alarm in accordance with 9.6.3 throughout the building, and both of the following also shall apply:
o (a)
Positive alarm sequence in accordance with 9.6.3.4 shall be permitted.
o (b)
A presignal system in accordance with 9.6.3.3 shall be permitted.
" (2)
Occupant notification shall be permitted to be made via a voice communication or public address system in accordance with 9.6.3.9.2.
Based on document review and interview, the facility failed to provide occupant notification of the fire alarm.
The findings included:
Document review and interview with the Director of Facilities Management on 02/05/2025 at 11:54 AM, revealed the facility had a fire that started in an office next to the kitchen in the basement of The Vanderbilt Clinic building. At the time of the fire the fire alarm system was placed on "test" and fire alarm notification devices were bypassed due to a renovation project in the area.
Interview with staff members #4 and #5 between 12:47 PM and 1:05 PM, revealed during the fire incident staff member #5 pulled the fire alarm but neither staff member heard any fire alarms going off. Both staff members proceeded to manually notify others in the area of the fire and started assisting in evacuations of the area.
Interview with the Construction Coordinator and Director of Facilities Management, at the time of the shut down of the fire alarm notification appliances no fire watch or Interim Life Safety Measures were being conducted.
NFPA 101, 39.3.4.3 (2012 Edition)
The Accreditation & Regulatory Specialist acknowledged these findings during the telephone exit conference on 02/07/2025.
Fire Alarm System - Out of Service
Tag No.: K0346
Based on document review and interview, the facility failed to provide occupant notification of the fire alarm.
The findings included:
Document review and interview with the Director of Facilities Management on 02/05/2025 at 11:54 AM, revealed the facility had a fire that started in an office next to the kitchen in the basement of The Vanderbilt Clinic building. At the time of the fire the fire alarm system was placed on "test" and fire alarm notification devices were bypassed due to a renovation project in the area.
Interview with staff members #4 and #5 between 12:47 PM and 1:05 PM, revealed during the fire incident staff member #5 pulled the fire alarm but neither staff member heard any fire alarms going off. Both staff members proceeded to manually notify others in the area of the fire and started assisting in evacuations of the area.
Interview with the Construction Coordinator and Director of Facilities Management at the time of the shut down of the fire alarm notification appliances no fire watch or Interim Life Safety Measures were being conducted.
NFPA 101, 9.6.1.6 (2012 Edition)
The Accreditation & Regulatory Specialist acknowledged these findings during the telephone exit conference on 02/07/2025.