HospitalInspections.org

Based on Life Safety Code complaint investigation findings (KS00127515; ASPEN #BYDB21), the hospital did not meet the applicable provisions of the current Life Safety Code (LSC) when they failed to have an area under constuction sprinklered; failed to have a 1 hour fire wall separation, and failed to perform a fire watch when the sprinkler system was down for over a month. The hospital's failure to ensure the building under construction met the LSC requirements placed all patients, workers, staff, and visitors at risk for fire or smoke spreading to other parts of the building. The hospital had a census of 25 at the time of the LSC survey.

Findings include:

- Review of the LSC complaint investigation results dated 03/13/18 showed, the LSC Inspector discovered on 03/12/18 that the sprinkler in a storage room and hallway of a construction area was not operational. The construction area did not have a 1 hour fire wall separation and further, the hospital did not complete a fire watch to reduce the risk of fire and smoke spreading to other parts of the building. (Refer to A-0709 for further details).

This deficient practice resulted in the LSC inspector of the Office of the State Fire Marshal's 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 03/13/18 at 12:30 PM that was not removed by exit.

Based on Life Safety Code complaint investigation findings (KS00127515; ASPEN #BYDB21), the hospital did not meet the applicable provisions of the current Life Safety Code (LSC) when they failed to have an area under constuction sprinklered; failed to have a 1 hour fire wall separation between the work zone and occupied portion of the building; and failed to perform a fire watch when the sprinkler had been out of service for over a month. The hospital's failure to ensure the building under construction met the LSC requirements placed all patients, workers, staff, and visitors at risk for fire or smoke spreading to other parts of the building. The hospital had a census of 25 at the time of the LSC survey.

Findings include...

- Review of the LSC complaint investigation survey dated 03/13/18 showed, the LSC Inspector discovered on 03/12/18:

1:15 PM - The storage room and hallway in the construction area did not have sprinkler protection.

1:35 PM - The hospital did not have a 1 hour rated fire wall separation between the work zone and the occupied portion of the buidling. The temporary wall between the areas of the building had exposed metal studs.

2:00 PM - The hospital did not complete a fire watch to reduce the risk of fire and smoke spreading to other parts of the building when the sprinkler system had been out of service for the past month.

This deficient practice resulted in the LSC inspector of the Office of the State Fire Marshal's 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 03/13/18 at 12:30 PM. The hospital did not remove the IJ prior to exit.