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Based on observation, document review, policy review, interview and review of the Life Safety Code complaint investigation findings (ASPEN #HETF21; KS00170091), the hospital failed to meet the applicable provisions of the current Life Safety Code (LSC) when they failed to ensure that portable space heaters were not being used within the facility and all non-clinical electrical equipment is inspected and are code compliant.

The cumulative effects of this deficient practice has the potential to increase the risk of fire placing all patients, staff, and visitors at this facility at risk for harm, injury or death.


Findings Include:


1. The hospital failed to meet the applicable provisions of the current Life Safety Code (LSC) when they failed to ensure that portable space heaters were not being used within the facility. (Refer to Tag A-0709)

2. The hospital failed to ensure facilities, supplies, and equipment are maintained to an acceptable level of safety and quality when it failed to ensure all non-clinical electrical equipment is electrically safe to use. (Refer to Tag A-0724)

Based on document review, policy review, interview, and review of the Life Safety Code complaint investigation findings (ASPEN # HETF21; KS00170091), the hospital failed to meet the applicable provisions of the current Life Safety Code (LSC) when they failed to ensure portable space heaters were not being used within the facility. This deficient practice has the potential to increase the risk of fire and has the potential to affect all patients, staff, and visitors at this facility.


Findings Include:


Review of the LSC complaint investigation results dated 03/09/22 showed on 03/04/2022, the Office of the Kansas Fire Marshal was notified by the facility that Ascension Via Christi Hospital St. Joseph had a reported fire incident earlier that morning due to a short in a cord from a space heater. Review of the Reported Fire Incident form indicates that the facility's staff noticed the smell of smoke and found the space heater sitting on a desk at a nurse's station that was plugged into a cubicle wall outlet. Staff pulled an alarm and used a dry chemical extinguisher to put out the fire, but no evacuation was completed. The plug was removed, and the fire department was told they could disregard the alarm. No damage was reported, other than to the space heater.

Review of a hospital policy titled, "Portable Space Heater," dated 05/2017, showed "It is the policy of Ascension Via Christi Hospitals Wichita to prohibit the use of space heaters in buildings that house patients overnight, and any building used for employee or staff sleeping ..."

During an interview on 03/16/22 at 12:20 PM, Staff E, Behavioral Health Technician, stated that on 03/04/22 at approximately 7:00 AM she heard a loud pop and when she looked, she saw flames coming from a wall outlet where a portable space heater had been plugged in. " ...When I looked, there was fire coming out of the outlet and was getting worse and flamed up maybe about a foot ..." Staff E stated another unidentified staff member grabbed a fire extinguisher and put out the flames. "I pulled the fire alarm after we extinguished the fire ...I know we didn't follow the right order of RACE and it says to rescue patients first, but it happened so quickly and we just acted to get the fire out as soon as possible ..."

During an interview on 03/17/22 at 8:03 AM, Staff K, Licensed Practical Nurse (LPN) stated, "There was a space heater that belonged to me that was plugged up. At the end of the shift there was a popping sound and fire was coming out of the wall outlet." She stated she went for a fire extinguisher but when she returned someone else had already extinguished the fire. Staff K confirmed that using a portable space heater is against hospital policy.

Review of a document titled, "Fire Response Plan," dated 01/2019 showed, " ...The first objective in any fire situation must be the immediate removal of persons at risk from the fire scene ...The fire alarm system must be activated immediately after all persons at risk have been removed from the fire and smoke scenes ... ...Extinguish; It is only with a great sense of caution that personnel should make the decision to fight a fire ..."


Review of a document titled "Space Heater/Equipment Fire Compliance Rounds," showed that on date of incident 03/04/22, one additional space heater was discovered on the 6th floor of the hospital and two space heaters were discovered on the 7th floor of the hospital.


During an interview on 03/16/22 at 12:46 PM, Staff C, Safety Officer stated that a facility audit was performed immediately following the fire incident on 03/04/22 and an undisclosed amount of space heaters were located throughout the hospital. Staff C verified that the space heaters were a violation of hospital policy and had not been inspected, tagged, or approved for use by the hospital.

Based on observation, policy review, and interview, the hospital failed to ensure facilities, supplies, and equipment are maintained at an acceptable level of safety and quality when it failed to ensure all non-clinical electrical equipment is safe to use. This deficient practice has the potential to increase the risk of fire and/or injury and has the potential to affect all patients, staff, and visitors at this facility.


Findings Include:


Review of a hospital policy titled, "Non-Clinical Equipment Electrical Testing," dated 08/2016, showed "It is the policy of Via Christi Hospital St. Joseph to ensure that non-clinical equipment is electrically safe to use ...The Facilities Management Department maintains non-clinical electrical equipment and is responsible for monitoring, repairing, inspecting, and maintaining records of inspections and repairs for non-clinical electrical equipment used in patient care areas ...Do not use staff-owned electrical equipment in patient care areas. This equipment includes, but is not limited to, radios, clocks, televisions, etc. ...The Facilities Management Department follows this protocol when inspecting equipment. Visual inspection ...Chassis to Ground Pin Resistance (testing performed to ensure electrical safety) ..."

Observation on 03/16/22 at 10:10 AM showed a microwave in the 6th floor staff lounge with an inspection tag dated 2020. The facility was not able to provide records of monitoring and inspections since date of original inspection.

Observation on 03/16/22 at 10:45 AM showed the 5th floor Intensive Care Unit (ICU) with a blender in the staff lounge and a radio at the nurse's station without an inspection tag.

Observation on 03/16/22 at 11:00 AM showed the 4th floor staff lounge with a toaster, two microwaves, three coffee pots and an air fryer without an inspection tag and a radio at the nurses' station without an inspection tag.

Observation on 03/16/22 at 11:20 AM showed the radiology department lounge with three microwaves, three refrigerators, a toaster, and a crockpot without an inspection tag.

During an interview on 03/16/22 at 12:46 PM, Staff C, Safety Officer stated that microwaves, refrigerators, and other electrical devices are required to be inspected and tagged. Staff C stated that equipment is only tagged upon initial inspection but no written records for further inspection, monitoring, or maintenance is kept on non-clinical electrical devices. "We do rounds monthly. We are looking at equipment on every round, but equipment is only tagged once ..."

During an interview on 03/16/22 at 1:58 PM, Staff I, Lead for Facilities, stated " ...anything that is brought into the hospital must be inspected and tagged. Devices are inspected by whoever is assigned to the floor for the month and rounds are completed monthly. Rounds include looking at everything. Everything is only tagged one time with a date at time of inspection and although it's looked at every month the tag is not updated with a new date.,," Staff I stated that the facility found "some items" during recent rounds that had not been inspected and had to be removed from the facility.