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BIG SOUTH FORK MEDICAL CENTER
Fire Alarm System - Testing and Maintenance
Tag No.: K0345
Based on observation and interview, it was determined the facility failed to ensure the fire alarm system was arranged to transmit the alarm automatically per the requirements of:
NFPA 101, 19.3.4.3.2.1 & 9.6.4.2;
This has the potential to affect 16 of 16 smoke compartments.
The Findings include:
1. Observation with the maintenance director in the emergency room on 9/27/2019 at 9:30 AM confirmed the fire alarm panel was indicating system trouble.
2. Interview with the maintenance director in the emergency room on 9/27/2019 at 9:31 AM confirmed the fire alarm was not being monitored. The maintenance director stated the system has not been monitored since the evening of 9/25 and a new contract for service is being arranged.
The maintenance director and human resource manager was present when the deficiencies were identified and acknowledged by the Chief Nursing Officer during the exit conference on 9/27/2019.