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Based on observations and interview, the facility failed to separate an area under construction from the rest of the building with a 1 hour fire rated construction barrier. This deficient practice would allow a fire to spread throughout the construction area into the hospital. The facility census was 6 patients.

Findings are:
Observations on 7-31-17 at 12:50 pm revealed, that the facility was undergoing a major renovation in the ED area. A temporary wall covered with plastic had been installed to separate the nonsprinkled ED construction area from the hospital. The wall did not provide a 1 hour fire rated separation.

During an interview on 7-31-17 at 12:50 pm, Administrative Staff A confirmed the lack of 1-hour fire rated separation between the construction and the hospital.

During an interview on 7-31-17 at 3:03 pm Administrative A and B, were advised that the deficient practice was determined to be of immediate jeopardy.

Based on observation and interview, the facility created a new dead end corridor, which exceeded the maximum allowed 30 feet, while undergoing a construction project. This deficient practice would cause confusion and delay egress from the Center Core Northwest Patient Wing. The facility census was 6 patients.

Findings are:
Observations on 7-31-17 at 12:18 pm revealed, a 60 foot dead end corridor had been created by the Center Core construction project in the Northwest Patient Wing. The dead end corridor left 4 patient rooms in the wing with only one exit.

During an interview on 7-31-17 at 12:18 pm, Facility Staff A confirmed the dead end corridor was created during construction..

During an interview on 7-31-17 at 3:03 pm Administrative A and B, were advised that the deficient practice was determined to be of immediate jeopardy.

Based on observations and interview, the facility failed to provide a complete and functioning fire alarm system in the ED corridor adjacent to the area undergoing a construction project. This deficient practice would delay the detection and notification of a fire which would affect all occupants. The facility census was 6 patients.

Findings are:
Observations on 7-31-17 at 11:20 am revealed that due to construction, the facility had removed the audible/visual fire alarm notification devices in a 176 foot portion of the ED corridor and that three smoke detectors in the area were not functional.

During an interview on 7-31-17 at 11:20 am, Administrative Staff A confirmed the fire alarm devices had been removed and altered by the contractor due to construction.

During an interview on 7-31-17 at 3:03 pm Administrative A and B, were advised that the deficient practice was determined to be of immediate jeopardy.

Observations on 7-31-17 at 5:18 pm revealed that the fire alarm devices in the ED corridor had been re-installed and tested, and were in working condition. Due to the measures put in place, the immediate jeopardy was abated.

Based on interview and observation, the facility failed to implement a fire watch during a major construction project after fire alarm notification devices and detection devices had been removed or altered and were non-functional. This deficient practice would not provide detection and notification of a fire and would affect all occupants. The facility census was 6 patients.

Findings are:

Observations on 7-31-17 at 11:20 am revealed that due to construction, the facility had removed the audible/visual fire alarm notification devices in a 176 foot portion of the ED corridor and that three smoke detectors in the area were not functional.

During an interview on 7-31-17 at 1:00 pm Administrative Staff A, indicated the facility was not providing a fire watch in areas under construction that were affected by the non-functional fire alarm devices.

During an interview on 7-31-17 at 3:03 pm Administrative A and B, were advised that the deficient practice was determined to be of immediate jeopardy.

Observations and documentation review on 7-31-17 at 5:15 pm revealed facility had started a Fire Watch. Due to the measures put in place, the immediate jeopardy was abated.

Observations on 7-31-17 at 5:18 pm revealed that the fire alarm devices in the ED corridor had been -re-installed and tested.

Based on observation and interview, the facility failed to implement a fire watch during a major construction project when sprinkler heads were obstructed and impaired by a temporary construction barrier. The facility census was 6 patients.

Findings are:

Observations on 7-31-17 at 2:33 pm revealed a temporary construction barrier had been installed in the ED corridor. The spinkler heads in the ED corridor were located on one side of the barrier resulting in no sprinkler protection on the other side. Numerous sprinkler heads were not in proper orientation with the ceiling tile and numerous heads were missing escutcheons.

During an interview on 7-31-17 at 2:33 pm Administrative Staff A revealed the facility was not in fire watch status even though the sprinklers had been impaired for more than 10 hours.

During an interview on 7-31-17 at 3:03 pm Administrative A and B, were advised that the deficient practice was determined to be of immediate jeopardy.

Observations and documentation review on 7-31-17 at 5:15 pm revealed facility had started a Fire Watch. Due to the measures put in place, the immediate jeopardy was abated.