The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

VIOLATION: Building Rehabilitation Tag No: K0111
NFPA 101 Building Rehabilitation

Building Rehabilitation
Repair, Renovation, Modification, or Reconstruction
Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following:
* Requirements of Chapter 18 and 19
* Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6,,
Change of Use or Change of Occupancy
Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by or (4.6.7 and 4.6.11), (4.6.7 and 4.6.11), (43.7)
Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2 hour fire resistance rating constructed of materials as required for the addition.
Communicating openings occur only in corridors and are protected by approved self closing fire doors with at least a 1 1/2 hour fire resistance rating. Additions comply with the requirements of Section 43.8. (4.6.7 and 4.6.11), (8.3),,, (4.6.7 and 4.6.11), (8.3),,,
This STANDARD is not met as evidenced by:

Based upon observation, a review of records and staff interview, the facility fails to assure that a building undergoing, repair, renovation, modification, or reconstructions complies with the requirements of Chapter 18 and 19. The deficient practice increases the risk of fire or smoke spreading to other areas of the building, affecting all patients, visitors and staff in 1 of 11 smoke zones including the facilities cafeteria.

Findings include: During the 50% construction inspection beginning at 3:20 PM on June 5th, 2018, it is observed:

1. At 3:40 the doorway from the new addition project to the existing occupied area of the hospital is observed not to be fire rated, and the wall section above this doorway is observed to be incomplete leaving openings directly connected to the occupied portion of the hospital. It is observed that there is no sprinkler protection in the new addition under construction.
2. At 3:45 the opening between the southwest area of the project and the occupied pre/op suite is observed to be two pieces of fire rated plywood without the ability to latch. They only way to close these doors are by an unrated hook and clasp type system. Gaps of approximately 1 inch are observed around the entire cover where it is hung from the wall. These openings were made on 5/18/18 and were left open for ease of access to and from the job area.
Administrative staff A and construction personnel A and B, and project management personnel A and B were present and acknowledged the findings.

The facility was placed into immediate jeopardy status at 4:00 PM, and placed into fire watch. This immediate jeopardy was abated at 4:15 when the facility began fire watch operations. 1 hour rated walls were constructed over the openings and completed at 7:07 PM, and the facility ceased fire watch operations.

NFPA 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,

NFPA Standard: Protection shall be provided to separate an occupied portion of the structure from the area undergoing alteration, construction, or demolition operations when such operations are considered as having a higher level of hazard than the occupied portion of the building. Walls shall have at least a 1 hour fire resistance rating and openings shall have at least a 45 minute fire protection rating. Non rated walls and openings shall be permitted when an approved automatic sprinkler system is installed. 2012 NFPA 241, 8.6.2