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Based upon a review of records and staff interview, the facility failed to inspect and test the facilities medical gas system and provide a documented maintenance program for medical gas and vacuum piped systems. The deficient practice reduces the reliability of the medical gas system affecting all patients within the facility in 2 of 4 smoke zones. The facility has a capacity of 15 with a census of 2 at the time of this survey.

Findings include:

During the routine survey/complaint on August 7th & 8th, 2018 the following observations were made:

Based on record review on Tuesday August 7th, 2018, at approximately 12:00 p.m. it was discovered that the Wilson Medical Center facility does not have documentation of inspection or testing of the medical gas system or an established maintenance program for the same.


Staff Members A1, A2, A3 and M1 were present during the finding and acknowledged the finding.


Review of the following NFPA Standard revealed: Medical gas storage and administration areas shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing. 2012 NFPA 101, 19.3.2.4

Review of the following NFPA Standard revealed: Health care facilities with installed medical
gas, vacuum, WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed. 2012 NFPA 99, 5.1.14.2.1

Review of the following NFPA Standard revealed: Persons maintaining these systems shall be qualified to perform these operations. Appropriate qualification shall be demonstrated by any of the following:

(1) Training and certification through the health care facility by which such persons are employed to work with specific equipment as installed in that facility
(2) Credentialing to the requirements of ASSE 6040, Professional Qualification Standard for Medical Gas Maintenance Personnel
(3) Credentialing to the requirements of ASSE 6030, Professional Qualification Standard for Medical Gas Systems Verifiers
2012 NFPA 99, 5.1.14.2.2.5

Review of the following NFPA Standard revealed: Central supply systems for nonflammable medical gases shall conform to the following:
(1) They shall be inspected annually.
(2) They shall be maintained by a qualified representative of the equipment owner.
(3) A record of the annual inspection shall be available for review by the authority having jurisdiction.
2012 NFPA 99, 5.1.14.4.4

Review of the following NFPA Standard revealed: A periodic testing procedure for nonflammable medical gas and vacuum and related alarm systems shall be implemented. 2012 NFPA 99, 5.1.14.4.5