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Based on document review and Life Safety Code (LSC) complaint investigation findings (KS00130168; ASPEN #7DVG21), the hospital failed to meet the applicable provisions of the current LSC when they failed to have at least a one hour fire separation between the construction area and the occupied areas of the hospital.

This deficient practice placed the hospital patients, staff, and visitors at risk for fire spreading more quickly to other areas of the building.

Findings include:

- Review of the LSC complaint investigation results dated 06/06/18 revealed the LSC Inspector discovered on 06/05/18, two openings and a wall above a non fire rated door, open with no separation from the new addition to the occupied area of the hospital. There should have been at least a one hour separation between the construction area and the occupied areas of the hospital. (Refer to A-0709 for further details).

Based on document review and Life Safety Code (LSC) complaint investigation findings (KS00130168; ASPEN #7DVG21), the hospital failed to meet the applicable provisions of the current LSC when they failed to have at least a one hour fire separation between the construction area and the occupied areas of the hospital.

This deficient practice placed the hospital patients, staff, and visitors at risk for fire spreading more quickly to other areas of the building.

Findings include:

1. Observation by the LSC inspector on 06/05/18 at 3:40 PM, the facility failed to maintain proper one hour separation between the existing occupied portion of the building and the unsprinklered new addition project. Two openings were observed that did not have proper one hour separation. The door on the northeast side of the new addition was of a hard plastic construction type temporary door that is not fire rated. The entire length of the wall above this door was open above with no separation between the new addition and the occupied portion. The southwest opening was protected with two fire rated sheets of plywood. This was designed as a swinging type door with only a hasp to close the door. Gaps greater than 1 inch were observed around the framing used to connect the door to the wall.

2. The LSC Inspector called the Office of the State Fire Marshal's Field Supervisor to report the findings The facility administrator and construction staff were notified that this situation placed them in immediate jeopardy (IJ - a situation in which non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) status at 4:00 PM. The hospital removed the IJ at 4:15 PM on 06/05/18 by performing a fire watch. The hospital constructed one hour rated walls over the openings by 7:07 PM on 06/05/18 and the facility ceased fire watch operations.

3. Refer to LSC survey report (ASPEN #7DVG21) for further details (K-111).

4. National Fire Protection Association (NFPA) Standard: Buildings shall be permitted to be occupied during construction, repair, alterations, or additions only when required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the AHJ are in place. 2012 NFPA 101, 4.6.10.1

5. NFPA Standard: Protection shall be provided to separate an occupies portion of the structure form the area undergoing alteration, construction, or demolition operations when such operations are considered as having a higher level of hazard than the occupied portion of the building. Walls shall have at least a 1 hour fire resistance rating and opening shall have at least a 45 minute fire protection rating. 2012 NFPA 241, 8.6.2