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Based on observation and record review and staff interview, it was determined that the facility failed to assure proper construction separation in accordance with National Fire Protection Association (NFPA) 101 life safety code which resulted in an Immediate Jeopardy (IJ a situation in which the providers noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairments, or death to a patient) finding. This deficiency affects all patients, residents, staff, and visitors in the facility with serious bodily injury and or death in all smoke zones.

Findings Include:

Observation during the survey on 05/11/21 between 10:00 AM and 10:45 AM showed the following:

1. It was observed and verified by interview of Construction Staff C and Administration Staff A at 10:30 AM that patients, visitors, and staff were at risk due to the construction separation being diminished below the required one hour separation at the emergency room (ER) renovation project. The existing two hour fire barrier was also reduced to one hour in the patient isolation room project. This resulted in an IJ.

The IJ template was delivered at 4:41 PM and the facility removed the IJ when they submitted a credible plan of removal on 05/11/21 at 5:25 PM. Actions on the plan of removal included:
a. Adding a firewall to meet the one hour separation requirement for the ER renovation project.
b. Adding a firewall to meet the two hour separation requirement for the patient isolation room project.

Administration Staff A and Construction Staff C were present and acknowledged the findings.

NFPA Standard revealed:

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)
Additions
Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition.
Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8.
18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8)

Based on observation and staff interview, the facility taped smoke detectors to prevent dust alarms for a 24 hour time frame in two of two construction zones (patient isolation room and emergency room (ER) renovation project). The facility failed to provide documentation of a fire watch logs while the fire alarm systems was impaired.

This resulted in an Immediate Jeopardy (IJ a situation in which the providers noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairments, or death to a patient) finding. This deficiency has the potential to affect all patients, residents, staff, and visitors in al smoke zones.

Findings Include:

Observation during the survey on 05/11/21 between 10:00 AM and 10:45 AM showed the following:

The construction area for the negative patient isolation room at 10:10 AM revealed taped smoke detectors

During an interview with Construction Staff C and Administration Staff A on 05/11/21 at 10:16 AM, it was found that all staff responded with insufficient knowledge on proper fire watch execution and the facility could not provide documentation of a fire watch.

The construction area of the ER renovation project at 10:20 AM, also revealed taped smoke detectors.

Administration Staff A and Construction Staff C acknowledged the findings.

The IJ template was delivered at 4:41 PM and the facility removed the IJ when they submitted a credible plan of removal on 05/11/21 at 5:25 PM. Actions on the plan of removal included:
a. Removing the tape from the smoke detectors in the construction area for the negative patient isolation room.
b. Removing the tape from the smoke detectors in the construction area of the ER renovation project.
c. Conducting a fire watch and log hourly anytime it is necessary to tape the smoke detectors.

NFPA Standard revealed:

Fire Alarm - Out of Service
Where required fire alarm system is out of services for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.
9.6.1.6