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Based on document review and Life Safety Code survey findings (ASPEN #XFD121), the hospital failed to meet the applicable provisions of the current Life Safety Code (LSC) when they failed to have their construction plans reviewed prior to starting the project which led to obstruction of a means of exiting and failure to ensure required fire features like a one hour fire resistance wall were in place.

The hospital's failure to have their construction plans reviewed placed all staff, patients, and visitors at risk for not being able to exit the building in a speedy fashion in case of an emergency and at risk for not having fire protections in place.

Findings include:

- Review of the LSC survey results dated 7/11/2017 on 7/27/17 revealed the LSC Inspector discovered the following on 7/5/2017:

1. The hospital failed to have the second floor construction project reviewed by the Office of the State Fire Marshal prior to beginning the project.
2. The north exit corridors on the second floor had been blocked off.
3. The construction walls dividing the 2nd floor project area from the patient area were not constructed to the required one hour fire resistance (Refer to A-0709 for further details).

This deficient practice 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 (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/resident) on 7/5/2017 at approximately 11:20 am. The hospital removed the immediate jeopardy on 7/5/2017 at 3:37 pm by the hospital having the construction company clean up and remove the temporary walls, reinstall doors, and replace the smoke detectors. Additionally, the maintenance and facilities manager contacted the fire alarm company to ensure the system was fully functional.

Based on document review and Life Safety Code survey findings (ASPEN #XFD121), the hospital failed to meet the applicable provisions of the current Life Safety Code (LSC) when they failed to have their construction project plans reviewed prior to starting the project; by obstructing a means of exiting on the 2nd floor by putting up temporary construction walls and by failing to ensure required fire features like a one hour fire resistance wall were in place.

The hospital's failure to have their construction plans reviewed placed all staff, patients, and visitors at risk for not being able to exit the building in a speedy fashion in case of an emergency and at risk for not having fire protections in place.

Findings include:

- Review of the LSC survey (ASPEN #SFD121) results dated 7/11/2017 on 7/27/17 revealed the LSC Inspector discovered the following on 7/5/2017 and 7/6/2017 between 10:30 am and :

1. The hospital had a capacity of 58 with a current census of 21.

2. The LSC inspector noticed that the fire alarm panel was showing trouble in the system.

3. Maintenance tech A indicated that there was a construction project being started on the second floor that required the removal of smoke detectors from a portion of the hallway and so the system (fire alarm) had been placed on test.

4. During presurvey of the hospital, there was no record of a current construction project. The Office of the State Fire Marshal had not performed a plan review of this project prior to it starting.

5. The corridors to the end of the North hallway had been terminated by a new wall constructed out of drywall and metal studs to prevent others from entering the construction area. The walls were not rated to the required one hour fire resistance and eliminated the remote exit for the North and center smoke zones. There was a non-rated door in one of the corridor walls.

6. On 7/5/2017 at approximately 11:20 am, 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 (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/resident).

6. The hospital removed the immediate jeopardy on 7/5/2017 at 3:37 pm by having the construction company clean up, remove the temporary construction walls, reinstall doors, and replace the smoke detectors. Additionally, the maintenance and facilities manager contacted the fire alarm company to ensure the system was fully functional.


Refer to the attached Life Safety Code survey results dated 7/11/17 (ASPEN # XFD121) for additional details and NFPA references.