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Based on observation, interview, policy review and Life Safety Code (LSC) complaint investigation (KS00156216, ASPEN#CFZ121), the hospital failed to meet the applicable provisions of the current LSC when they failed to ensure staff were notified the fire alarm system was offline for testing, resulting in delay notification of patients, visitors and staff in the event of the fire in the MRI (Magnetic Resonance Imaging - a test that uses powerful magnets, radio waves, and a computer to make detailed pictures of the inside of your body) room, failed to ensure the pre-action suppression system (Pre-action pipes start out as dry pipes; they hold water back using an electronic "pre-action" valve. This system requires two events to happen before any sprinklers discharge: 1. The pre-action valve will only activate when an independent fire detection system detects a fire. Upon alert, the pre-action valve releases, water flows in, and the system essentially becomes a wet pipe system. 2. Now that water is on deck, one or more individual sprinkler heads need to release to engage and discharge water) was designed and installed to operate as a supervised, automatic sprinkler system, and failed to ensure staff are trained on the pre-action system operation. This deficient practice has the potential to cause delay in notification of a fire and affects all occupants of the hospital placing them at risk for injury, harm, or even death.

Findings Include:

Review of the LSC complaint investigation results dated 09/25/20 revealed the maintenance staff failed to notify all hospital staff that the fire alarm system was taken off line for testing resulting in a significant delay in notification of a potential fire in the MRI room. The MRI technician pulled two different fire pull stations located outside of the MRI testing room that failed to function. The pre-action suppression system was inaccessible to the MRI staff during the fire due to the location of the manual activation button being more than 200 feet away and the staff lacked training to activate the pre-action suppression system. This resulted in a fire that burned through the ceiling and flooring of the MRI room, burning the MRI machine, charring the walls of the MRI room and blowing off the vent in the roof above the MRI machine. The fire led to the loss of the MRI machine and the hospital's inability to provide this service to patients.

This deficient practice resulted in the LSC inspector of the office of the state fire marshal (OSFM) 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 entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death) on 09/25/20 around 11:30 AM.

The hospital removed the LSC immediate jeopardy on 09/25/20 at 5:15 PM by submitting a credible plan of removal that included the following:

1. The hospital's undated policy titled, "Fire Alarm Down," showed ...when the fire alarm system is in "walk test" for routine testing or any other reason, a notification will be sent to the areas affected via email and overhead announcement ...during this time if there is a fire, the staff will call 2580 (code phone) and follow normal fire response protocols. Maintenance staff will then turn the fire alarm system back on and activate the alarm system.

2. The hospital's undated policy titled, "Sprinkler System Down," showed ...when the sprinkler system is in "walk test" for a routine testing or any other reason, a notification will be sent out to the areas affected via email and overhead announcement ...During this time if there is a fire, the staff will call 2580 (code phone) and follow normal fire response protocols. Maintenance staff will then turn the system back on and activate the system.

3. Education was provided to all staff in the immediate work area and all staff who are required to respond to emergencies in that area. Training was provided on 09/28/20 (no time noted) and verified by staff signatures to confirm their understanding. The OSFM staff verified the sign in sheets.

4. Education will also be provided upon hire, and on an annual basis as part of the Emergency Preparedness Plan.

5. A fire watch was initiated in the MRI suite on 09/29/20 at 9:18 AM and will be maintained until an approved correction is made to the location of the pre-action suppression system.

6. Business Y (fire and smoke alarm system company), Business X (sprinkler system company), and the architect from Business Z came on site on 09/29/20 at 11:00 AM to develop a plan for the re-location of the pre-action suppression system.

7. Training was provided to all staff in the immediate work area and staff who are required to respond to emergencies in that area regarding the current location of the manual activation device for the pre-action suppression system. Staff were brought to the current location of the manual activation device and signed they understand the location and the purpose of the device. The OSFM staff verified the signature sheets. The staff will be re-educated with the new location of this manual activation device for the pre-action suppression system.

8. Education will also be provided upon hire, and on an annual basis as part of the Emergency Preparedness Plan.


(Refer to A-0709 and LSC 2567 ASPEN #CFZ121 for further details).

Based on observation, interview, document review, and policy review the hospital failed to ensure emergency lighting in one of five operating rooms (OR 4), in one of two sterile processing areas (dirty processing room), in one of one intensive care unit (ICUs), one of one emergency department (ED), one of one acute care/COVID-19 area, and one of one stairwell. The hospital also failed to ensure emergency flashlights in one of one ICU and in one of one pharmacy. Failure of the hospital to ensure emergency lighting has the potential for disrupted patient care (to include surgeries, birthing, and respiratory dependent patients) and unsafe evacuation routes in case of fires or other needs to clear the building.

Findings Include:

Document review of an article from the National Fire Protection Association (NFPA), titled, "Verifying the emergency lighting and exit marking when reopening a building," dated 07/01/20, showed ...NFPA 101m Life Safety Code requires emergency lighting to be provided in designated stairs, aisles, corridors and passageways leading to an exit ...the emergency lighting is designed to automatically illuminate for at least 90 minutes upon the loss of power.

Document review of the hospital's emergency power policies showed the facility failed to have a policy concerning battery backup lighting.

Observation on 09/24/20 at 12:33 PM, in OR 4 and the dirty room of the sterile processing area (where the surgical instruments are waiting to be sterilized) showed the battery backup lights failed to come on during a test of the lights.

During an interview on 09/24/20 at 12:33 PM, in OR 4 and the dirty room of the sterile processing area, Staff C, Facility's Management Supervisor verified upon testing the emergency backup lights in OR 4 and the dirty side of the sterile processing room the battery backup lights failed to work.


During an observation/interview on 09/24/20 at 11:45 AM, in the ICU, Staff C, Facility's Management Supervisor stated that he is not sure what lights are the emergency backup lights. He thinks it is every two to three lights and he would need to check the print outs.

During an observation/interview on 09/24/20 at 11:51 AM in the ED, Staff C, Facility's Maintenance Supervisor stated that he is not sure which lights are the battery backup lights. He thinks they may be every two to three ceiling lights, but he is not sure.


During an observation/interview on 09/24/20 at 12:02 PM, in the acute care/COVID-19 floor, Staff C, Facility's Maintenance Supervisor stated that he is not sure what lights would provide battery backup in the case of a power shortage.


During an observation/interview on 09/24/20 at 12:49 PM in the stairwell, Staff C, Facilities Management Supervisor was not sure where the backup lighting was and made a call to a tech who works on the electrical parts of the facility and the tech told Staff C, they are fine, and they work. Staff C failed to provide logs to verify the location of the backup lighting and testing.


Observation on 09/24/20 at 11:45 AM in the ICU, Staff L, ICU Director stated that emergency flashlights in the nurse's area failed to be found, but there was one in each ICU rooms.


During an observation/interview on 09/24/20 at 12:23 PM in the pharmacy, Staff S, Pharmacy Technician, stated that she cannot find any backup flashlights or batteries, and she was not sure where she would go to find the closest fire pull station, but she commented she would just call her supervisor.

Based on observation, interview, documents review, record review and Life Safety Code (LSC) complaint investigation findings (KS00156216, ASPEN # CFZ121), the hospital failed to meet the applicable provisions of the current LSC when maintenance staff failed to ensure notification to hospital staff that the fire alarm system was offline for testing, failed to ensure the pre-action suppression system (Pre-action pipes start out as dry pipes; they hold water back using an electronic "pre-action" valve. This system requires two events to happen before any sprinklers discharge: 1. The pre-action valve will only activate when an independent fire detection system detects a fire. Upon alert, the pre-action valve releases, water flows in, and the system essentially becomes a wet pipe system. 2. Now that water is on deck, one or more individual sprinkler heads need to release to engage and discharge water) was automatic and failed to ensure hospital staff were trained to manually activate the pre-action suppression system during a fire. This deficient practice has the potential to delay response to fires in the hospital resulting in harm, injury, or even death.

Findings Include:

1. On 09/22/20, the Facility's Management Supervisor failed to alert all hospital staff the fire alarm system was offline for testing, which resulted in an MRI (Magnetic Resonance Imaging (a test that uses powerful magnets, radio waves, and a computer to make detailed pictures of the inside of your body) technician pulling two fire pull stations that failed to alert patients, visitors, and staff of a fire in the MRI suite.

2. During an interview on 09/24/20 at 3:38 PM, Staff C, Facility's Management Supervisor stated that he generally does not notify the hospital employees when the fire alarm system is turned off for this annual test since it is such a short time as this is how I was instructed years ago.

3. During an interview on 09/24/20 at 4:11 PM, Staff I, MRI Technician stated that on 09/22/20, she saw the MRI room filling with smoke. Staff I activated the two emergency stop buttons for the MRI including the one that stops electricity to the room and one that quenches the MRI magnet. She went out to talk with the ultrasound technicians and asked them to take the patient (Patient 1) out of the MRI room and to call maintenance about the fire. She quickly pulled the fire alarm, but it did not sound, so she reached across the hall about six feet and tried the other fire pull station, but it failed to work as well.

4. Review of Patient 1's medical record showed Patient 1 had an MRI test on 09/22/20 at 11:00 AM and it was noted that she smelled smoke during the MRI test. This resulting in her going to the emergency department shortly after her discharge home with complaints of a headache and nausea.

5. During an interview on 09/28/20 at 12:38 PM, Staff N, Senior Customer Engineer stated that both emergency shut off buttons functioned as they should. This was a unique situation and he commented that if the sprinkler system would have worked as expected, we may not have had so much damage.

6. Review of the LSC survey report ASPEN # CFZ121 showed, according to the National Fire Protection Agency (NFPA) 19.3.5.3, "Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5". It further showed that the hospital's pre-action suppression system was not automatic, and it was inaccessible to staff located more that 200 feet away from the MRI and a floor below the MRI Suite and the hospital staff had not been trained to manually activate the pre-action suppression system.

See LSC 2567 ASPEN #CFZ121 for further details.

Based on observation, interview, document review and policy review the hospital failed to ensure a sanitary environment by controlling infections and communicable disease as evidence by Staff W, Registered Nurse (RN) failing to perform hand hygiene and clean non-disposable equipment during the care of three of three patients (Patients 2, 3, and 4); by failing to mix cleaning disinfectants in appropriate concentrations; and by failing to provide all housekeeping staff training related to COVID-19. Failure of the hospital to ensure a sanitary environment by controlling infections and communicable disease has the potential for all patients, visitors and staff to be at risk for acquiring cross-contamination of bacteria, viruses including COVID-19, and communicable diseases.

Findings Include:

Document review of the hospital's undated policy titled, "Coronavirus (COVID-19) Management and Control Plan/Protocol," showed ...healthcare personnel will perform hand hygiene frequently, including before and after all patient contact, contact with potentially infectious material, and before and after removal of PPE and gloves ...hand hygiene includes either washing with soap and water or using alcohol-based hand sanitizer.

Document review of the hospital's policy titled, "Standard Precautions - Infection Control," dated 11/02/07, showed ...standard precautions include practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which health care is delivered ...gloves shall be worn when the employee has the potential for the hands to have direct skin contact with, other infectious materials, mucous membranes, and when handling items or surfaces soiled with blood or other potentially infectious materials ...hand hygiene ...employees shall wash their hands immediately or as soon as possible after patient contact or removal of gloves or other potentially infectious materials ...alcohol gel can be used in place of traditional hand washing except when hands are visibly soiled.

Observation on 09/29/20 at 8:24 AM, Staff W, RN, Acute Care entered Patient 3's room and during his assessment reaching into her pocket with her dirty gloved hand she pulled out an alcohol wipe to use with the patient medications. She later put a new trash bag in the trash can with her bare hands and failed to clean her hands with soap and water or hand sanitizer. Immediately after that she picked up the unused IV bag and patient's plastic medication tray and took it back to the medication room, opened the medication room door and placed the IV bag and medication tray back in the drawer potentially cross contaminating the Medication room and drawer. She then took out another patient's medication tray and went to her desktop computer at the nurses' station to verify the medications without performing hand hygiene throughout this whole time potentially cross contaminating the other patient's medications, the desktop computer and the nurses' station.


Observation on 09/29/20 at 8:37 AM, Staff W, RN, Acute Care entered Patient 2's room and then quickly left the room to get the patient a drink of soda. Staff W failed to use hand sanitizer upon leaving the room and on entrance back into the room. The patient requested to use the rest room and Staff W (with gloves on) went to get a thick plastic gait belt (used to secure the patient for safety with transfers and walking). The gait belt fell on the floor and Staff W picked it up off the dirty floor to use on Patient 2. The patient stated that she did not need it and was independent in walking to the rest room. Staff W then placed the dirty gait belt back on a hook in the room without cleaning it and wearing the same dirty gloves from handling the gait belt, entered data on the computer contaminating the keyboard, and then took her badge out of the machine on the desk with her dirty gloves and clipped it back on her t-shirt. Staff W picked up the gait belt that had fallen on the dirty floor again, emptied the measuring cup with the patient's urine from the toilet and took off her gloves. Staff W failed to use hand sanitizer or wash her hands after removing her gloves. Staff W then picked up the patient's medication tray, opened the door to the medication room, put the medication tray away, went back to the nurses' station and documented something on the desktop computer without performing hand hygiene again and potentially cross contaminated the medication room door, the medication trays, the nurses' station and the desktop computer.

Observation on 09/29/20 at 9:03 AM, Staff W, RN, Acute Care entered Patient 4's room. The patient asked for his cell phone which had fallen on the dirty floor and Staff W picked it up with her gloved hands handed it to the patient. Staff W continued to prepare and administer Patient 4's medications without removing her dirty gloves and/or performing hand hygiene. She put her same dirty gloved hand into her pants pocket to take out an alcohol wipe and continued with the same dirty gloves to clean the IV port and administer a medication. Then, Staff W took her gloves off and failed to use hand sanitizer or wash her hands. Staff W cleaned the supplies from the desk in Patient 4's room with dirty hands, then picked up the medication tray, opened the medication room door, and placed the medication tray in the drawer potentially contaminating the medication room door, and the medication trays.

During an interview on 09/29/20 at 9:14 AM, Staff W, RN, Acute Care acknowledged she failed to perform hand hygiene correctly for all three patients.


Document review of the hospital's undated policy titled, "Coronavirus (COVID-19) Management and Control Plan/Protocol," showed ...patient care equipment ...all non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer's instructions and hospital policies.

Document review of the hospital's undated handout titled, "Gel In - Gel Out," showed ...please clean your stethoscope with an alcohol wipe in between patients.

Observation on 09/29/20 at 8:24 AM, Staff W, RN, placed her stethoscope on Patient 3's bare chest to listen for heart sounds and then over his gown for bowel sounds and on his back for lung sounds. She failed to disinfect her stethoscope after use and placed the dirty stethoscope around her neck where it laid on the t-shirt she was wearing.

Observation on 09/29/20 at 8:37 AM, Staff W, RN, placed her dirty stethoscope on Patient 2's gown to listen to her heart sounds, bowel sounds, and lung sounds and failed to disinfect the stethoscope potentially cross contaminating Patient 2 with germs from Patient 3. Staff W placed the dirty stethoscope around her neck and allowing it to touch/rest upon her t-shirt.

Observation on 09/29/20 at 9:03 AM, Staff W, RN, placed her dirty stethoscope on Patient 4, touching his abdominal skin and chest with the stethoscope potentially cross contaminating Patient 4 with germs from Patient 3 and Patient 2. Staff W again failed to disinfect the dirty stethoscope and placed it around her neck and onto her t-shirt.

During an interview on 09/29/20 at 9:14 AM, Staff W, RN, Acute Care acknowledged she failed to disinfect her stethoscope during her assessments of Patient 3, Patient 2, and Patient 4.


Document review of the hospital's undated policy titled, "Coronavirus (COVID-19) Management and Control Plan/Protocol," showed ...dedicated nursing staff will follow manufacturer's instructions and hospital policy for cleaning and disinfection of environmental surfaces and equipment. Routine cleaning and disinfection of the PPE doffing area.

Document review of the hospital's updated, "Environmental Services Handbook" failed to show information related to the preparation of chemicals for cleaning in the hospital.

Observation on 09/29/20 at 9:18 AM, Staff X, Housekeeper was asked if the cleaning solution met the standards to kill COVID-19 and she said she thought it did. Staff X was asked how she measures the cleaning solutions and she said, "I just eye ball it." Staff X was asked if they have any special way of measuring the solution and she said yes, but she does not use that method. She was also asked if she mixes the cleaning solution for anything else besides her routine cleaning and she said she fills the cleaning bottles the nurses use at the nurse's station. Staff X was also asked what cleaning solution she uses to clean the COVID-19 rooms and she shared they use a bleach and water solution and she just mixes it on her own without using any measurements. The cleaning bottles failed to show the concentration of the solution.

Observation on 09/29/20 at 9:26 AM, Staff Y, Housekeeping Supervisor showed us two different disinfectant stations all housekeeping staff can use that is pre-mixed with the correct amount of solution and water. Staff Y was asked if this method of pre-mixing is always accurate and she shared at times it is not, and if the color is too light they are to mix in a little more cleaning solution until it looks right. Staff Y also shared if the mixing stations break down the company will send out a new one quickly. Staff Y also showed us a jet pack that is filled with the cleaning solution and they put the hard-plastic pack on their backs and spray all items in each room and let it set for at least 10 minutes for a total disinfection of everything in each room upon discharge. She shared they use a bleach and water solution that is also measurable at the station for the staff to use when cleaning the COVID-19 rooms. Staff Y was not able to clarify the exact ratio of bleach to water they use when cleaning the COVID-19 rooms.

Document review of the hospital's undated policy titled, "Coronavirus (COVID-19) Management and Control Plan/Protocol," showed ...all persons entering the patient room will wear at least: (follow KDHE guidelines) ...a power air purifying respirator (PAPR) with full head piece (disposable), with attached HEPA filter.

During an interview on 09/29/20 at 9:18 AM, Staff X, Housekeeper stated that she does have to clean the COVID-19 rooms at times and she does not wear an N95 mask when she cleans, as she prefers the blue paper masks instead.

Document review of the hospital's undated policy titled, "Coronavirus (COVID-19) Management and Control Plan/Protocol," showed the hospital failed to include information concerning staff training requirements.

During an interview on 09/29/20 at 9:18 AM, Staff X, Housekeeper stated that she has not received any specific COVID-19 training.

During an interview on 09/29/20 at 9:26 AM, Staff Y, Housekeeping Supervisor stated that she has not received any specific COVID-19 training.