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929 NORTH ST FRANCIS STREET

WICHITA, KS 67214

PHYSICAL ENVIRONMENT

Tag No.: A0700

Based on document review and Life Safety Code complaint investigation findings (KS00126765; ASPEN #8UNH21), the hospital failed to meet the applicable provisions of the current Life Safety Code (LSC) when they failed to submit plans for the temporary means of exit needed for their construction project and allowed patients, visitors, and staff in the corridor with no means of exiting in case of an emergency. This deficient practice placed all patients, visitors, and staff in this smoke zone at risk for not being able to exit timely in an emergency situation when evacuation is required.

Findings include:

- Review of the LSC complaint investigation results dated 2/20/2018 revealed the LSC Inspector discovered on 2/19/2018 a dead-end corridor on the southeast end of the 6th floor which is 124 feet from the nearest exit stairwell (over 4 times the allowed length according to the National Fire Protection Agency). This dead end corridor also affected hospital A which is located on the north end of the 6th floor of Via Christi Hospitals Wichita, Inc. Hospital A had 5 current patients in this area. (Refer to A-0709 for further details).

This deficient practice resulted in the LSC inspector of the state fire marshal's office notifying the hospital's administration that the Centers for Medicare and Medicaid Services (CMS) identified this as an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) on 2/19/2018 around 2:00 pm. The hospital removed the immediate jeopardy on 2/19/2018 at 4:37 pm by moving all patients, visitors, and staff out of the corridor and posting signage not allowing persons into the area.

LIFE SAFETY FROM FIRE

Tag No.: A0709

Based on document review and Life Safety Code complaint investigation findings (KS00126765; ASPEN #8UNH11), the hospital failed to meet the applicable provisions of the current Life Safety Code (LSC) when they failed to submit plans for the temporary means of exit needed for a construction project on the southeast end of the 6th floor, thus creating an 124 foot dead-end corridor which would not allow the patients, visitors, and staff a timely means of exiting in case an emergency situation requiring evacuation. Additionally, this dead-end corridor impacted hospital B, which is located on the north end of the 6th floor of Via Christi Hospitals Wichita, Inc.

Findings include:

1. Observation by the LSC inspector on 2/19/2018, the hospital was completing a renovation project of the Southeast portion of the 6th floor.

2. Observation by the LSC inspector on 2/19/2018, the construction project taking place on the south end of the 6th floor created a dead end corridor of 124 feet. An exit sign shows egress into the corridor but a construction wall has been built in front of the stairwell preventing exiting.

3. According to the National Fire Protection Agency (NFPA) 2012 101 requirement 19.2.5.2, Dead end corridors shall not exceed 30 feet. Existing dead end corridors greater than 30 feet shall be permitted to be continued to be used if it is impractical and unfeasible to alter them.

4. Observation by the LSC inspector on 2/19/2018, there are 5 current patients from hospital B and all visitors and staff in this smoke zone are affected. Some staff have been allowed to occupy offices affected by this dead end corridor.

5. On 2/19/2018 at around 2:00 pm, the LSC inspector, on behalf of the Centers for Medicare and Medicaid Services (CMS), notified the facility that this situation was an immediate jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient).

6. Observation by the LSC inspector on 2/19/2018 at 4:37 pm, the corridor had been evacuated and signs posted not allowing persons into the area. The hospital had removed the immediate jeopardy for both hospital B and itself.