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Based on the life safety code (LSC) complaint survey (ASPEN #6ITJ21; KS00173923) findings, the critical access hospital failed to ensure that the piped-in oxygen 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 being provided with the minimum amount of oxygen flow from the wall outlet. The deficient practice affects patients in (3) emergency rooms and all patient care rooms. The facility has 25 certified beds and a census of 2 patients at the time of the survey.

Findings Include:

Review of documentation during a routine LSC survey at 11:36 AM on 08/10/22 revealed that the facility had not established a maintenance program for their piped-in oxygen system as required by NFPA 99.

During an interview, Maintenance Staff A stated they did not have an inspection or testing program implemented for the piped-in oxygen system. He stated that the facility had a contract with Advance Compliance Solutions to upgrade the entire system. The initial bid for replacement was received by the hospital on 02/18/22.

The hospital administration was notified at 2:59 PM on 08/10/22 that this deficiency represents an IJ and they were placed into fire watch at 3:00 PM pending removal of the IJ.

The hospital removed the IJ on 08/10/22 at 5:07 PM when they submitted a plan to shut off the piped-in oxygen supply and notified staff to utilize oxygen e-cylinders until the new system was installed. The hospital shut off the oxygen valves and the life safety code inspector verified the oxygen valves were shut off at 5:10 PM.

Refer to C-0930 and the LSC findings ASPEN #6ITJ21 at K-907 for further details.

Review of documentation during a routine LSC survey at 11:36 AM on 08/10/22 revealed that the facility had not had their piped-in oxygen system inspected annually as required by NFPA 99.

During an interview, Maintenance Staff A stated that they did not have knowledge of the system ever having been inspected previously. He stated that the facility had a contract with Advance Compliance Solutions to upgrade the entire system. The initial bid for replacement was received by the hospital on 02/18/22.

The hospital administration was notified at 2:59 PM on 08/10/22 that this deficiency represents an IJ and they were placed into fire watch at 3:00 PM pending removal of the IJ.

The hospital removed the IJ on 08/10/22 at 5:07 PM when they submitted a plan to shut off the piped-in oxygen supply and notified staff to utilize oxygen e-cylinders until the new system was installed. The hospital shut off the oxygen valves and the life safety code inspector verified the oxygen valves were shut off at 5:10 PM.

Refer to C-0930 and the LSC findings ASPEN #6ITJ21 at K-908 for further details.

Based on the life safety code (LSC) complaint survey (ASPEN #6ITJ21; KS00173923) findings, the critical access hospital failed to ensure that the piped-in oxygen 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 being provided with the minimum amount of oxygen flow from the wall outlet. The deficient practice affects patients in (3) emergency rooms and all patient care rooms. The facility has 25 certified beds and a census of 2 patients at the time of the survey.

Findings Include:

Review of documentation during a routine LSC survey at 11:36 AM on 08/10/22 revealed that the facility had not established a maintenance program for their piped-in oxygen system as required by NFPA 99 and that the facility had not had their piped-in oxygen system inspected annually as required by NFPA 99.

During an interview, Maintenance Staff A stated they did not have an inspection or testing program implemented for the piped-in oxygen system. He stated that the facility had a contract with Advance Compliance Solutions to upgrade the entire system. The initial bid for replacement was received by the hospital on 02/18/22.

The hospital administration was notified at 2:59 PM on 08/10/22 that this deficiency represents an IJ and they were placed into fire watch at 3:00 PM pending removal of the IJ.

The hospital removed the IJ on 08/10/22 at 5:07 PM when they submitted a plan to shut off the piped-in oxygen supply and notified staff to utilize oxygen e-cylinders until the new system was installed. The hospital shut off the oxygen valves and the life safety code inspector verified the oxygen valves were shut off at 5:10 PM.

NFPA review: 5.1.14.2.3.1 General. The elements in 5.1.14.2.2.2 through 5.1.15 shall be inspected or tested as part of the maintenance program as follows:
(1)*Medical air source, as follows:
(a) Room temperature
(b) Shaft seal condition
(c) Filter condition
(d) Presence of hydrocarbons
(e) Room ventilation
(f) Water quality, if so equipped
(g) Intake location
(h) Carbon monoxide monitor calibration
(i) Air purity
(j) Dew point
(2)*Medical vacuum source - exhaust location
(3) WAGD source - exhaust location
(4)*Instrument air source - filter condition
(5)*Manifold sources (including systems complying with 5.1.3.5.10, 5.1.3.5.11, 5.1.3.5.12, and 5.1.3.5.13), as follows:
(a) Ventilation
(b) Enclosure labeling
(6) Bulk cryogenic liquid source inspected in accordance with NFPA 55, Compressed Gases and Cryogenic Fluids Code
(7) Final line regulation for all positive pressure systems -delivery pressure
(8)*Valves - labeling
(9)*Alarms and warning systems-lamp and audio operation
(10) Alarms and warning systems, as follows:
(a) Master alarm signal operation
(b) Area alarm signal operation
(c) Local alarm signal operation
(11)*Station outlets/inlets, as follows:
(a) Flow
(b) Labeling
(c) Latching/delatching
(d) Leaks
5.1.14.4.4 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.

Refer to LSC findings ASPEN #6ITJ21 at K-907 and K-908 for further details.