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Based on observation, policy review and Life Safety Code (LSC) complaint investigation findings (ASPEN #HIFN21, KS00144994) the hospital failed to meet the applicable provisions of the current LSC by failing to implement a fire watch when the sprinkler system was impaired in two of two construction areas (the Prep/Recovery and EP (electrophysiology) Lab projects.

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 at the time of survey.

Findings Include:

1. On 08/27/19 the Office of the State Fire Marshal's Fire Protection Specialist performed a 50% inspection on the prep/recovery and EP Lab projects. It is observed at 9:00 AM that the ceiling tiles and grid have been removed from the prep/recovery suite undergoing construction. Multiple walls have been rearranged creating areas without sprinkler protection. Throughout the suite there are approximately 8 feet between the sprinkler head deflector and the ceiling deck. Many of the sprinkler heads are on flex piping and have been laid over without support and are positioned parallel with the floor. Cylinders used for hot work and large amounts of combustible storage are observed throughout the space. This work zone is not separated from the occupied portion of the hospital by 1 hour fire rated construction. The temporary partition wall between the corridor and the partition wall separating the occupied pre/post of patient area are constructed of one layer of ½ inch drywall with exposed studs on the construction side. A non ducted supply airline is running through the construction zone and into the occupied corridor through a grate that does not have a fire damper.

2. On 08/27/19 at 9:20 AM the inspection progressed to the EP Lab portion of the project. The ceiling grid is observed removed throughout the space. This creates an approximate 8 foot gap between the sprinkler deflectors and the ceiling deck. In the two procedure rooms, with drywall ceilings, the sprinklers are observed with the protective caps stills covering the sprinkler heads. There are not proper 1 hour fire rated walls separating the construction from the occupied portion of the building. Many of the previous corridor door openings have had the doors removed and one layer of ½ inch drywall has been placed over the openings. No fire rated door frame is provided at the door to enter/exit the construction zone from the corridor, and there are two non ducted air supply vents running to the corridor from the work zone.

3. On 08/27/19 at 9:30 AM the Fire Prevention Supervisor was called, and the findings were reported. The Fire Prevention Supervisor arrived at the hospital at 10:20 AM. The supervisor confirmed the findings, and the facility was placed into immediate jeopardy status at 10:40 AM. The facility immediately removed the immediate jeopardy when they began a fire watch at 11:00 AM. The facility plans to remain in fire watch until the sprinkler system can be corrected and is no longer impaired.

4. During interview and policy review on 8/27/19 at 11:00 AM, and 1:00 PM, it is revealed that the facility's written policy for implementing a fire watch for sprinkler system impairment is to have taken affect anytime the sprinkler system is out of service for more than 10 hours. The policy states under the purpose heading, " During periods of maintenance, construction, or renovation the fire alarm or fire suppression system may be taken out of service for short periods of time. The purpose of this process is to allow OPRMC to determine when the fire watch will be required and for what duration." The policy also states under the scope heading, "Actions must be taken prior to taking the fire alarm or fire suppression system out of service and the recommendations are identified in the scope. This process must be placed in effect if one of the two following conditions are scheduled or unscheduled: 1. Where a required fire alarm system is out of service for more than 4 hours in a 24 hour period. 2. Where a required fire protection system is out of service for more than 10 hours in a 24 hour period." Under the hospitals fire watch worksheet point 1 states, "A fire watch must be in place anytime a fire protection system is impaired. However, at the time of the 50% inspection, a portion of the sprinkler system had been significantly impaired for approximately 30 days, and walls had been rearranged creating areas without sprinkler protection without a fire watch being performed.

Refer to A-0709 for further details.

Refer to LSC complaint survey findings (ASPEN #HIFN21, KS00144994) for additional information.

Based on observation, policy review and Life Safety Code (LSC) complaint investigation findings (ASPEN #HIFN21, KS00144994) the hospital failed to meet the applicable provisions of the current LSC by failing to implement a fire watch when the sprinkler system was impaired in two of two construction areas (the Prep/Recovery and EP (electrophysiology) Lab projects.

This deficient practice placed all patients, visitors, and staff at risk for fire or smoke spreading to other areas of the building.

Findings Include:

1. On 08/27/19 the Office of the State Fire Marshal's Fire Protection Specialist performed a 50% inspection on the prep/recovery and EP Lab projects. It is observed at 9:00 AM that the ceiling tiles and grid have been removed from the prep/recovery suite undergoing construction. Multiple walls have been rearranged creating areas without sprinkler protection. Throughout the suite there are approximately 8 feet between the sprinkler head deflector and the ceiling deck. Many of the sprinkler heads are on flex piping and have been laid over without support and are positioned parallel with the floor. Cylinders used for hot work and large amounts of combustible storage are observed throughout the space. This work zone is not separated from the occupied portion of the hospital by 1 hour fire rated construction. The temporary partition wall between the corridor and the partition wall separating the occupied pre/post of patient area are constructed of one layer of ½ inch drywall with exposed studs on the construction side. A non ducted supply airline is running through the construction zone and into the occupied corridor through a grate that does not have a fire damper.

2. On 08/27/19 at 9:20 AM the inspection progressed to the EP Lab portion of the project. The ceiling grid is observed removed throughout the space. This creates an approximate 8 foot gap between the sprinkler deflectors and the ceiling deck. In the two procedure rooms, with drywall ceilings, the sprinklers are observed with the protective caps stills covering the sprinkler heads. There are not proper 1 hour fire rated walls separating the construction from the occupied portion of the building. Many of the previous corridor door openings have had the doors removed and one layer of ½ inch drywall has been placed over the openings. No fire rated door frame is provided at the door to enter/exit the construction zone from the corridor, and there are two non ducted air supply vents running to the corridor from the work zone.

3. On 08/27/19 at 9:30 AM the Fire Prevention Supervisor was called, and the findings were reported. The Fire Prevention Supervisor arrived at the hospital at 10:20 AM. The supervisor confirmed the findings, and the facility was placed into immediate jeopardy status at 10:40 AM. The facility immediately removed the immediate jeopardy when they began a fire watch at 11:00 AM. The facility plans to remain in fire watch until the sprinkler system can be corrected and is no longer impaired.

4. During interview and policy review on 8/27/19 at 11:00 AM, and 1:00 PM, it is revealed that the facility's written policy for implementing a fire watch for sprinkler system impairment is to have taken affect anytime the sprinkler system is out of service for more than 10 hours. The policy states under the purpose heading, " During periods of maintenance, construction, or renovation the fire alarm or fire suppression system may be taken out of service for short periods of time. The purpose of this process is to allow OPRMC to determine when the fire watch will be required and for what duration." The policy also states under the scope heading, "Actions must be taken prior to taking the fire alarm or fire suppression system out of service and the recommendations are identified in the scope. This process must be placed in effect if one of the two following conditions are scheduled or unscheduled: 1. Where a required fire alarm system is out of service for more than 4 hours in a 24 hour period. 2. Where a required fire protection system is out of service for more than 10 hours in a 24 hour period." Under the hospitals fire watch worksheet point 1 states, "A fire watch must be in place anytime a fire protection system is impaired. However, at the time of the 50% inspection, a portion of the sprinkler system had been significantly impaired for approximately 30 days, and walls had been rearranged creating areas without sprinkler protection without a fire watch being performed.

5. Construction personnel and hospital EHS staff were present and acknowledged the findings and state that this situation has been in place for approximately 4 weeks, starting in late July.

6. NFPA (National Fire Protection Association) Standard: Buildings shall be permitted to be occupied during construction, repair, alterations, or additions only when required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the AHJ are in place. 2012 NFPA 101, 4.6.10.1

NFPA Standard: Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above; through any concealed spaces, such as those above suspended ceilings; and through interstitial structural and mechanical spaces, unless otherwise permitted by 19.3.6.2.4 through 19.3.6.2.8.
Corridor walls shall have a minimum 1?2 hour fire resistance rating.
Corridor walls shall form a barrier to limit the transfer of smoke.
In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, a corridor shall be permitted to be separated from all other areas by non fire rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke. 2012 NFPA 101, 19.3.6.2.1, 19.3.6.2.2, 19.3.6.2.3, 19.3.6.2.4

Review of the following NFPA Standard revealed: Sprinkler System Impairments. Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems. 2012 NFPA 101, 9.7.6

Review of the following NFPA Standard revealed: All preplanned impairments shall be authorized by the impairment coordinator. 2011 NFPA 25, 15.5.1

Review of the following NFPA Standard revealed: Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24 hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b) An approved fire watch
(c) Establishment of a temporary water supply
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site. 2011 NFPA 25, 15.5.2

Review of the following NFPA Standard revealed: Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure. When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.
The coordinator shall implement the steps outlined in Section 15.5. 2011 NFPA 25, 15.6.1, 15.6.2 & 15.6.3

Review of the following NFPA Standard revealed: Restoring Systems to Service. When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have been implemented:
(1) Any necessary inspections and tests have been conducted to verify that affected systems are operational. The appropriate chapter of this standard shall be consulted for guidance on the type of inspection and test required.
(2) Supervisors have been advised that protection is restored.
(3) The fire department has been advised that protection is restored.
(4) The property owner or designated Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
representative, insurance carrier, alarm company, and other authorities having jurisdiction have been advised that protection is restored.
(5) The impairment tag has been removed 2011 NFPA 25, 15.7