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Based on observation, policy review and Life Safety Code complaint investigation findings (ASPEN #LTQM21, KS001141369 and ASPEN #ZGPS21, KS00141372) the hospital failed to meet the applicable provisions of the current Life Safety Code (LSC) by failing to implement a fire watch when the sprinkler system was impaired in two of two construction areas (Heart hospital (CTR CV Lab) and Bell hospital (PET control room and Operating Room (OR) control desk).

This deficient practice placed all patients, visitors, and staff at risk for fire or smoke spreading to other areas of the building. The facility had a census of 720 at the time of survey.

Findings Include:

1. Observation on 05/14/19, the Office of the State Fire Marshal's Fire Protection Specialist performed a 50% construction inspection on the CTR CV Lab project located on the 2nd floor of the heart hospital. It was observed at 10:15 AM that the ceiling tiles had been removed from the work area on the NE portion of the project. There was no interstitial space in this area, leaving approximately 10 feet between the existing pendant style head and the roof deck. This would result in greatly impairing the sprinkler systems ability to operate under fire conditions.

2. Observation on 05/14/19 at 10:25 AM, the 50% inspection progressed to the NW portion of the building under going the same project. At this time, ceiling tiles were observed removed in this space resulting in approximately 10 feet of space between the existing pendant style sprinkler head and the ceiling. This work area was also not properly separated by 1-hour construction.

3. Interview during the inspection, hospital Environmental Health and Safety personnel, administration, and construction personnel discussed that this project had been in this condition for approximately six weeks.

4. Observation on 05/14/19, the Office of the State Fire Marshal's Fire Protection Specialist performed a 50% construction inspection on the PET control room project located on the 2nd floor of the Bell Hospital. It was observed at 10:26 AM that the ceiling tiles had been removed from the work area on the PET control room project. There was an interstitial space lid in most of this room with sprinklers above the lid in the interstitial space. However, the existing pendant sprinklers below this lid exceeded the maximum allowed space between the deflector and the ceiling. This work zone was observed to not be properly separated by 1-hour construction in lieu of being sprinkler protected. Exposed studs were observed in the walls, with plastic sheeting also being used as separation.

5. Observation on 05/14/19 at 10:30 AM, the 50% inspection progressed to the operating room control desk project located on the 2nd floor of the Bell Hospital. At this time, the sprinkler heads in the main room were observed to be removed with open pipes showing where the sprinkler heads would be positioned. Sprinkler heads were provided above the interstitial space, however there was an approximate 20' X 20' area of this room without sprinkler coverage. This would result in greatly impairing the sprinkler systems ability to operate under fire conditions. The work zone was also not properly separated by 1-hour construction in lieu of being sprinkler protected. The wall separating the hallway of the work zone from the occupied portion of the suite had metal studs exposed as well as large portions of the walls near the ceiling covered in plastic sheeting. Interview during the inspection, hospital Environmental Health and Safety personnel, administration, and construction personnel discussed that this project had been in this condition for approximately 14 days.

6. Review of the facility's fire watch policy showed that "a fire watch is to be initiated whenever the sprinkler is impaired for greater than four hours".

7. The Fire Protection Specialist notified the construction company that sprinkler protection or complete 1-hour fire rating would be needed for the entire work zones in the Heart and Bell hospitals, and fire watch would be needed until the work was completed. The facility was placed in fire watch at 10:37 AM on 05/14/19. The facility received an order to cease work at 10:45 AM until the sprinkler system was no longer impaired or 1-hour separation was in place. The facility was placed in immediate jeopardy ( IJ - represents 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) status at 11:35 AM.

8. The facility immediately removed the IJ on 05/14/19 by conducting fire watches in all of the construction areas. On 5/14/19 at 6:19 PM, the facility submitted photos showing installation of sprinkler heads in the operating room area of the Bell hospital, so the fire watch ceased in this area.

Refer to A-0709 for further details.

Refer to LSC complaint survey findings (ASPEN #LTQM21, KS001141369 and ASPEN #ZGPS21, KS00141372) for additional information.

Based on observation, policy and document review, and Life Safety Code complaint investigation findings (ASPEN #LTQM21, KS001141369 and ASPEN #ZGPS21, KS00141372) the hospital failed to meet the applicable provisions of the current Life Safety Code (LSC) by failing to implement a fire watch when the sprinkler system was impaired in two of two construction areas (Heart hospital (CTR CV Lab) and Bell hospital (PET control room and Operating Room (OR) control desk).

This deficient practice placed all patients, visitors, and staff at risk for fire or smoke spreading to other areas of the building. The facility had a census of 720 at the time of survey.

Findings Include:

1. Observation on 05/14/19, the Office of the State Fire Marshal's Fire Protection Specialist performed a 50% construction inspection on the CTR CV Lab project located on the 2nd floor of the heart hospital. It was observed at 10:15 AM that the ceiling tiles had been removed from the work area on the NE portion of the project. There was no interstitial space in this area, leaving approximately 10 feet between the existing pendant style head and the roof deck. This would result in greatly impairing the sprinkler systems ability to operate under fire conditions.

2. Observation on 05/14/19 at 10:25 AM, the 50% inspection progressed to the NW portion of the building under going the same project. At this time, ceiling tiles were observed removed in this space resulting in approximately 10 feet of space between the existing pendant style sprinkler head and the ceiling. This work area was also not properly separated by 1-hour construction.

3. Interview during the inspection, hospital Environmental Health and Safety personnel, administration, and construction personnel discussed that this project had been in this condition for approximately six weeks.

4. Observation on 05/14/19, the Office of the State Fire Marshal's Fire Protection Specialist performed a 50% construction inspection on the PET control room project located on the 2nd floor of the Bell Hospital. It was observed at 10:26 AM that the ceiling tiles had been removed from the work area on the PET control room project. There was an interstitial space lid in most of this room with sprinklers above the lid in the interstitial space. However, the existing pendant sprinklers below this lid exceeded the maximum allowed space between the deflector and the ceiling. This work zone was observed to not be properly separated by 1-hour construction in lieu of being sprinkler protected. Exposed studs were observed in the walls, with plastic sheeting also being used as separation.

5. Observation on 05/14/19 at 10:30 AM, the 50% inspection progressed to the operating room control desk project located on the 2nd floor of the Bell Hospital. At this time, the sprinkler heads in the main room were observed to be removed with open pipes showing where the sprinkler heads would be positioned. Sprinkler heads were provided above the interstitial space, however there was an approximate 20' X 20' area of this room without sprinkler coverage. This would result in greatly impairing the sprinkler systems ability to operate under fire conditions. The work zone was also not properly separated by 1-hour construction in lieu of being sprinkler protected. The wall separating the hallway of the work zone from the occupied portion of the suite had metal studs exposed as well as large portions of the walls near the ceiling covered in plastic sheeting. Interview during the inspection, hospital Environmental Health and Safety personnel, administration, and construction personnel discussed that this project had been in this condition for approximately 14 days.

6. Review of the facility's fire watch policy showed that "a fire watch is to be initiated whenever the sprinkler is impaired for greater than four hours".

7. The Fire Protection Specialist notified the construction company that sprinkler protection or complete 1-hour fire rating would be needed for the entire work zones in the Heart and Bell hospitals, and fire watch would be needed until the work was completed. The facility was placed in fire watch at 10:37 AM on 05/14/19. The facility received an order to cease work at 10:45 AM until the sprinkler system was no longer impaired or 1-hour separation was in place. The facility was placed in immediate jeopardy ( IJ - represents 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) status at 11:35 AM.

8. The facility immediately removed the IJ on 05/14/19 by conducting fire watches in all of the construction areas. On 5/14/19 at 6:19 PM, the facility submitted photos showing installation of sprinkler heads in the operating room area of the Bell hospital, so the fire watch ceased in this area.

9. Observation during tours of the construction sites on 05/15/19 from 8:31 AM until 10:30 AM of the Heart Hospital and the Bell Hospital, accompanied by Staff A, University of Kansas Hospital Maintenance Director, Staff B, Infection Control Director, Staff AC, Environmental Health and Safety Director and various other construction executives and supervisors, and hospital administrators, showed no construction personnel present/working at the time of the tour except for the Administrative personnel to answer questions during the tour.

10. Interview at the time, construction had been halted since 05/14/19 at 12:00 PM when the Office of the State Fire Marshall surveyor called an IJ due to the sprinkler system being down for about a month in one area and a few weeks in the other area with no fire watch and a portion of the construction barrier is incomplete and does not provide the appropriate protection from fire.

11. Observation made of an unknown staff member conducting a fire watch. The hospital staff provided a log of personnel completing the fire watch and review of documentation showed staff had completed hourly watches of the required construction areas since the IJ was called on 05/14/19.

13. Interview during the tour, Staff A, Maintenance Director stated that construction would not start again until the report is received from the Fire Marshall, the Plan of Correction is accepted, and that may take up to 30 days.

14. Refer to LSC complaint investigation findings (ASPEN #LTQM21, KS001141369 and ASPEN #ZGPS21, KS00141372) for further details.