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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 interviews with facility administrative staff on 04/09/2025, revealed a fire was discovered in the pediatric emergency room on 04/02/2025. Fire alarm log data shows 3 pull station activations and 3 smoke detector activations.

Interview with facility administrative staff revealed that the audio/visual notification devices did not activate. Document review of the fire alarm log shows the fire alarm system was bypassed at the time of this incident.

Subsequent document review revealed 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.

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 facilities administration on 04/09/2025 at 10:30 AM, revealed the facility had a fire at the nurses station in the pediatric emergency room at approximately 7:20 PM. At the time of the fire the fire alarm system was placed on "test" and fire alarm notification devices were bypassed for unknown reasons.

Document review of facility provided event time line and fire alarm log shows 3 pull stations were activated by staff, and 3 smoke detectors also activated in the emergency department. Interview with facility administration revealed the audio/visual notification devices did not activate at any time during this event.

Subsequent document review of fire alarm log shows the fire alarm was bypassed for a total of 13 hours, 50 minutes, and 55 seconds on 04/02/2025, including during the incident time.

Interview with the Senior Accreditation Regulatory Specialist and subsequent review of the provided documentation from the facility revealed that 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 exit conference on 04/09/2025.