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Based on observation, interview, and review of records, the hospital failed to ensure that the medical gas system is maintained in accordance with the National Fire Protection Association (NFPA) 99 which resulted in an Immediate Jeopardy (IJ - a situation in which the providers noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairments or death to a patient) finding. This deficient practice failed to ensure patients are protected from unacceptable levels of carbon monoxide (CO) and to provide patients with the minimum amount of medical gas flow from outlets. The deficient practice affects all patients throughout the hospital. The facility has 47 certified beds and had a census of 13 at the time of survey.

Findings Include:

Documentation review on 11/23/20 at 1:00 PM of the annual Medical (Med) Gas Testing Report from a medical gas testing company dated 06/04/20 showed the following deficiencies:

1. Medical Gas Compressor Failed Bad Carbon Monoxide (CO - a colorless, odorless, and tasteless flammable gas that can be toxic) Sensor.
2. Medical Gas Compressor Failed Source valve not installed in proper location.
3. Vacuum Pump Failed Gas specific demand check valves are not installed on the main line, source pressure switch and gauge.
4. Med Gas Manifold Source valve is not installed in the proper location and labeled.
5. Thirteen outlets for the Medical Gas systems failed:
Operating Room (OR)1 vacuum drop outlet failed minimum flow test
OR1 vacuum wall outlet failed minimum flow test
OR2 vacuum boom outlet failed minimum flow test
OR2 nitrous oxide wall outlet failed minimum flow test
OR3 vacuum drop outlet failed minimum flow test
OR3 vacuum wall outlet failed minimum flow test
Oncology oxygen wall outlet leaking failed
Oncology vacuum wall outlet leaking failed
Emergency Room (ER) 4 oxygen wall outlet leaking failed
Room 220 oxygen wall outlet 1 leaking failed
Room 220 oxygen wall outlet 2 leaking failed
Room 229 oxygen wall outlet leaking failed
Room 240 vacuum wall outlet leaking failed

The facility received this inspection report on 06/25/20.

There is no documentation that the facility repaired or replaced any of the sensors or outlets since receiving this inspection report.

(Refer to A-0709 and LSC Complaint Report findings (KS00158095; ASPEN #S5G421; K-908 for further details).

Based on observation, interview, and review of records, the hospital failed to ensure that the medical gas system is maintained in accordance with the National Fire Protection Association (NFPA) 99 which resulted in an Immediate Jeopardy (IJ - a situation in which the providers noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairments or death to a patient) finding. This deficient practice failed to ensure patients are protected from unacceptable levels of carbon monoxide (CO) and to provide patients with the minimum amount of medical gas flow from outlets. The deficient practice affects all patients throughout the hospital. The facility has 47 certified beds and at the time of the survey had a census of 13 patients.

Findings Include:

Documentation review on 11/23/20 at 1:00 PM of the annual Medical (Med) Gas Testing Report from a medical gas testing company dated 06/04/20 showed the following deficiencies:

1. Medical Gas Compressor Failed Bad Carbon Monoxide (CO - a colorless, odorless, and tasteless flammable gas that can be toxic) Sensor.
2. Medical Gas Compressor Failed Source valve not installed in proper location.
3. Vacuum Pump Failed Gas specific demand check valves are not installed on the main line, source pressure switch and gauge.
4. Med Gas Manifold Source valve is not installed in the proper location and labeled.
5. Thirteen outlets for the Medical Gas systems failed:
Operating Room (OR)1 vacuum drop outlet failed minimum flow test
OR1 vacuum wall outlet failed minimum flow test
OR2 vacuum boom outlet failed minimum flow test
OR2 nitrous oxide wall outlet failed minimum flow test
OR3 vacuum drop outlet failed minimum flow test
OR3 vacuum wall outlet failed minimum flow test
Oncology oxygen wall outlet leaking failed
Oncology vacuum wall outlet leaking failed
Emergency Room (ER) 4 oxygen wall outlet leaking failed
Room 220 oxygen wall outlet 1 leaking failed
Room 220 oxygen wall outlet 2 leaking failed
Room 229 oxygen wall outlet leaking failed
Room 240 vacuum wall outlet leaking failed

The facility received this inspection report on 06/25/20.

There is no documentation that the facility repaired or replaced any of the sensors or outlets since receiving this inspection report.

During an interview on 11/23/20 at 1:05 PM, the Facility Maintenance Director (FMD) said that he had been in contact with a med gas repair contractor. The FMD indicated that the facility had no documentation of the repairs being completed. The medical gas testing company was contacted by the FMD at 1:30 PM. The medical gas testing company will have a repair tech onsite by 6:30 PM on 11/23/20 to make repairs.

The facility/Director of Quality Improvement (DQI) were notified at 5:26 PM on 11/23/20 that these deficiencies represent an Immediate Jeopardy.

The repair technician arrived at approximately 6:30 PM on 11/23/20 and worked until 1:00 AM installing and calibrating a new CO sensor and repairing med gas outlets that failed the pressure testing. Patient rooms 220, 229 and 240 could not be repaired by the repair tech at this time.

The hospital removed the IJ on 11/24/20 at 5:12 PM when they submitted the following plan:
The repair technician will return the week of 11/30/20 to repair the med gas outlets in Patient rooms 220, 229 and 240.
The facility has moved patients out of rooms 220, 229 and 240 until repairs are completed. The rooms are marked out of service and staff has been notified.
Once repairs are completed the facility will submit documentation of repairs to the Office of the State Fire Marshal.


Review of the following NFPA Standard revealed:
Medical Air Systems shall have operational pressure testing for their piped medical air systems.(NFPA 99) 5.1.12.3.10 Review of the following NFPA Standard revealed: 5.1.12.3.10 Operational Pressure Test. Operational
pressure tests shall be performed at each station outlet/inlet or terminal where the user makes connections and disconnections.
5.1.12.3.10.1 Tests shall be performed with the gas of system designation or the operating vacuum.
5.1.12.3.10.2 All gas outlets with a gauge pressure of 345 kPa (50 psi), including, but not limited to,
oxygen, nitrous oxide, medical air, and carbon dioxide, shall deliver 100 SLPM (3.5 SCFM) with a
pressure drop of not more than 35 kPa (5 psi) and static pressure of 345 kPa to 380 kPa (50 psi to 55
psi).

Refer to LSC Complaint Report findings (KS00158095; ASPEN #S5G421; K-908) for further details.