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Based on the life safety code (LSC) complaint survey (KS00162361; ASPEN #CKFF21) findings, the critical access hospital failed to ensure 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). In addition, the hospital failed to conduct a fire watch when the smoke detectors were impaired in the construction area for the negative patient isolation room and the emergency room (ER) renovation project. This, also resulted in an IJ.

The facility is approximately 44,402 square feet and two - two hour fire rated fire barriers, as well as four smoke zones. The building is not fully sprinklered. There is supervised smoke detection located in the corridors and in the spaces open to the corridors. The facility has one generator.

These deficiencies affected all patients, residents, staff, and visitors in the facility with serious bodily injury and or death in all smoke zones.

Findings Include:

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

1. The construction separation was diminished below the required one hour separation at the ER renovation project.

2. The existing two hour fire barrier was also reduced to one hour in the patient isolation room project.

3. The LSC inspector of the office of the state fire marshal (OSFM) notified Administration Staff A and Construction Staff C on 05/11/21 at 4:41 PM that this represented an IJ. The IJ was removed prior to survey exit when the hospital provided a plan of removal on 05/11/21 at 5:25 PM. The plan of removal included the following actions:
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.

(Refer to C-0930 and LSC Report #CKFF21, K-111 for further details)

4. The facility had taped smoke detectors to prevent dust alarms for a 24 hour time frame in the construction area for the negative patient isolation room and in the ER renovation project.

5. The facility failed to provide documentation of a fire watch while the fire alarm system was impaired with the taped smoke detectors.

6. The LSC inspector of the OSFM notified Administration Staff A and Construction Staff C on 05/11/21 at 4:41 PM that this represented an IJ. The IJ was removed prior to survey exit when the hospital provided a plan of removal on 05/11/21 at 5:25 PM. The plan of removal included the following actions:
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.

(Refer to C-0930 and LSC Report #CKFF21, K-346 for further details)

Based on the life safety code (LSC) complaint survey (KS00162361; ASPEN #CKFF21) findings, the critical access hospital failed to ensure 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). In addition, the hospital failed to conduct a fire watch when the smoke detectors were impaired in the construction area for the negative patient isolation room and the emergency room (ER) renovation project. This, also resulted in an IJ.

The facility is approximately 44,402 square feet and two - two hour fire rated fire barriers, as well as four smoke zones. The building is not fully sprinklered. There is supervised smoke detection located in the corridors and in the spaces open to the corridors. The facility has one generator.

These deficiencies affected all patients, residents, staff, and visitors in the facility with serious bodily injury and or death in all smoke zones.

Findings Include:

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

1. The construction separation was diminished below the required one hour separation at the ER renovation project.

2. The existing two hour fire barrier was also reduced to one hour in the patient isolation room project.

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

4. The LSC inspector of the office of the state fire marshal (OSFM) notified Administration Staff A and Construction Staff C on 05/11/21 at 4:41 PM that this represented an IJ. The IJ was removed prior to survey exit when the hospital provided a plan of removal on 05/11/21 at 5:25 PM. The plan of removal included the following actions:
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.

5. The facility had taped smoke detectors to prevent dust alarms for a 24 hour time frame in the construction area for the negative patient isolation room and in the ER renovation project.

6. The facility failed to provide documentation of a fire watch logs while the fire alarm system was impaired with the taped smoke detectors.

7. During and interview with Construction Staff C and Administration Staff A on 05/11/21 at 10:16 AM, staff responded with insufficient knowledge on proper fire watch execution and acknowledged they did not have fire watch logs.

8. The LSC inspector of the OSFM notified Administration Staff A and Construction Staff C on 05/11/21 at 4:41 PM that this represented an IJ. The IJ was removed prior to survey exit when the hospital provided a plan of removal on 05/11/21 at 5:25 PM. The plan of removal included the following actions:
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.

9. Review of the 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

(Refer to LSC Report #CKFF21, K-111 and K-346 for further details)