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Based on review of the Life Safety Code (LSC) complaint inspection findings (ASPEN #FLRV21; KS00134058), the hospital failed to meet the applicable provisions of the current National Fire Protection Agency's LSC when they had an area under construction (X-ray room 4) that was not properly sprinkler protected or separated from the other occupied areas of the hospital.

These deficiencies 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 (IJ- a situation in which a facility's non-compliance with one or more conditions of participation places patients at risk for harm, injury, or even death) on October 2, 2018 at 3:20 PM. The hospital removed the IJ on October 2, 2018 at 4:00 PM when they began fire watch operations.


Findings Include:

Observation by the Life Safety Code Inspector (LSC) during a routine hospital survey at approximately 2:30 PM on October 2, 2018 showed:

1. The hospital had begun construction on X-ray room 4. The hospital failed to construct a one-hour separation between the construction area and the areas occupied by patients, staff, and visitors. The entire Imaging Center smoke compartment is open to the construction area via the path from X-ray room 4 to the tech area that serves all the other imaging rooms. The door to X-ray room 4 from the corridor is a 20 minute rated door and the walls above the ceiling grid are not carried to the roof deck on two of the four sides.

2. The hospital removed the ceiling grid, allowing heat to bypass the sprinkler head.

3. The hospital had taken two pendant sprinklers and turned them upright, so the flow pattern is no longer functioning as they were designed.

4. The hospital had installed the smoke detector on a drop ceiling; when they removed the drop ceiling for construction, the smoke detector was not moved to the new ceiling height.

5. The hospital had covered the smoke detector with a plastic bag (causing it to not activate normally).

6. The hospital failed to notify and provide plans to the licensing agency (the Kansas Department of Health and Environment) or the Office of the State Fire Marshal prior to beginning this construction project.

Refer to A-0709 for further details.

Based upon observation, document review, and staff interview, the hospital failed to ensure that a building undergoing constructions complied with the applicable requirements of the National Fire Protection Agency (NFPA) by not having a one-hour separation between the construction area and the occupied area. Additionally, the hospital placed smoke detectors in locations where airflow prevents the normal operation of the detectors and covered the smoke detector with a bag, which prevented the detector from activation as intended.

These deficient practices increased the risk of fire or smoke spreading to other areas of the building, affecting all patients, visitors and staff in 1 of 11 smoke zones. Furthermore, these deficient practices may delay operation of the smoke detectors, delaying response to a fire situation, affecting all patients, staff and visitors in 1 of 11 smoke zones.

The hospital has a capacity of 47 with a census of 21 at the time of the survey..

Findings Include:

Observation by the Life Safety Code Inspector (LSC) during a routine hospital survey at approximately 2:30 PM on October 2, 2018 showed:

1. 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

NFPA Standard: Protection shall be provided to separate an occupied portion of the structure from 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 openings shall have at least a 45 minute fire protection rating. Non-rated walls and openings shall be permitted when an approved automatic sprinkler system is installed. 2012 NFPA 241, 8.6.2

Building Rehabilitation
CFR(s): NFPA 101

Building Rehabilitation
Repair, Renovation, Modification, or Reconstruction
Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following:
* Requirements of Chapter 18 and 19
* Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6
18.1.1.4.3, 19.1.1.4.3, 43.1.2.1
Change of Use or Change of Occupancy
Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2
18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7)

a. The hospital had begun construction on the room marked as X-ray room 4. The hospital failed to construct a one-hour separation between the construction area and the areas occupied by patients, staff, and visitors. The entire Imagining Center smoke compartment is open to the construction area via the path from X-ray room 4 to the tech area that serves all the other imaging rooms. The door to X-ray room 4 from the corridor is a 20 minute door and the walls above the ceiling grid are not carried to the roof deck on two of the four sides.

Refer to LSC Report (ASPEN #FLRV21;KS00134058) tag K-0111 for further details.

2. Review of the following NFPA Standard revealed:
NFPA 101 Building Rehabilitation
Building Rehabilitation
Repair, Renovation, Modification, or Reconstruction
Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following:
* Requirements of Chapter 18 and 19
* Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6
18.1.1.4.3, 19.1.1.4.3, 43.1.2.1
Change of Use or Change of Occupancy
Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2
18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7)

a. The hospital had taken two pendant sprinklers and turned them upright, so the flow pattern is no longer functioning as they were designed.

b. The hospital had removed the ceiling grid allowing heat to bypass the sprinkler head.

Refer to LSC Report (ASPEN #FLRV21;KS00134058) tag K-0354 for further details.

3. Review of the following NFPA Standard revealed: 9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101, 9.6.1.3

Review of the following NFPA Standard revealed: Specific Location Requirements. The installation of smoke alarms and smoke detectors shall comply with the following requirements:

(10) For tray-shaped ceilings (coffered ceilings), smoke alarms and smoke detectors shall be installed on the highest portion of the ceiling or on the sloped portion of the ceiling within 12 in. (300 mm) vertically down from the highest point.

a. The hospital had installed a smoke detector on a drop ceiling; when the hospital removed the drop ceiling, the hospital failed to move the smoke detector to the new ceiling height.

b. The hospital covered the smoke detector with a plastic bag (causing the smoke detector not to activate as it was intended).

Refer to LSC Report (ASPEN #FLRV21;KS00134058) tag K-0341 for further details.

4. Staff B and C were present and acknowledged the findings.

5. The LSC inspector of the state fire marshal's office notified the hospital's administration that the Centers for Medicare and Medicaid Services (CMS) identified this as an Immediate Jeopardy (IJ- a situation in which a facility's non-compliance with one or more conditions of participation places patients at risk for harm, injury, or even death) on October 2, 2018 at 3:20 PM.

6. The hospital removed the immediate jeopardy prior to survey exit on October 2, 2018 at 4:00 PM when they began fire watch operations.

7. The hospital failed to notify and provide plans to the licensing agency (the Kansas Department of Health and Environment) or the Office of the State Fire Marshal prior to beginning this construction project.