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Based on document review and Life Safety Code (LSC) complaint investigation findings (KS00156779; ASPEN #J4L921), the hospital failed to meet the applicable provisions of the current LSC when they failed to maintain the medical air system in working condition.

The facility has 58 certified beds and at the time of the survey had a census of 38 patients. The hospital had twenty patients scheduled for surgery on October 14, 2020 and twenty seven patients scheduled for surgery on October 15, 2020.

Findings Include:

Review of the LSC complaint investigation results revealed the LSC Inspector discovered during documentation review of the facility's annual Medical (Med) Gas Testing Report from Medical Technology Associates (MTA) dated March 2, 2020 showed the following deficiencies: 1) Carbon Monoxide (CO - a colorless, odorless, and tasteless flammable gas that can be toxic) Sensor failed. 2) Dew Point (the dew point is the lowest temperature that allows water vapor to remain in a gas without condensing to a liquid state) Sensor failed. 3) Seven outlets for the Operating Room's (OR's) vacuum system failed. The facility received this inspection report on March 10, 2020 and failed to show any documentation or proof that they had corrected these deficiencies.

This deficient practice had the potential to expose patients to unacceptable levels of CO and unacceptable levels of moisture in the medical air.

This deficient practice resulted in the LSC inspector of the Kansas State Fire Marshal's office notifying the hospital's administration that the Centers for Medicare and Medicaid Services (CMS) identified this as an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) on 10/13/20 at 5:17 PM. The hospital removed the immediate jeopardy on 10/13/20 at 8:04 PM by suspending all surgeries and procedures including heart catheterizations until the repairs on the CO sensor, Dew Point Sensor, and vacuum outlets in the OR were completed.

(Refer to A-0709 for further details).

Based on document review and Life Safety Code (LSC) complaint investigation findings (KS00156779; ASPEN #J4L921), the hospital failed to meet the applicable provisions of the current LSC as required by the National Fire Protection Agency (NFPA) when they failed to maintain the medical gas system for the hospital in working condition.

These deficiencies had the potential to expose patients to unacceptable levels of CO and unacceptable levels of moisture in the medical air.

The facility has 58 certified beds and at the time of the survey had a census of 38 patients. Twenty patients were scheduled for surgery on October 14, 2020 and twenty seven patients were scheduled for surgery on October 15.

Findings Include:

Documentation review during a routine survey on October 13, 2020 of the annual Medical (Med) Gas Testing Report from Medical Technology Associates (MTA) dated March 2, 2020 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 - Bad Dew Point (the dew point is the lowest temperature that allows water vapor to remain in a gas without condensing to a liquid state) Sensor.

3) Seven outlets for the Operating Room's (OR's) vacuum system failed:
OR2 Outlet 2 Leaking Failed Operational Pressure Test
OR2 Outlet 3 Leaking Failed Operational Pressure Test
OR3 Outlet 4 Leaking Failed Operational Pressure Test
OR4 Outlet 5 Leaking Failed Operational Pressure Test
OR6 Outlet 6 Failed Operational Pressure Test Needs New Latch Plate
OR6 Outlet 7 Failed Operational Pressure Test Needs New Latch Plate
OR6 Outlet 8 Failed Operational Pressure Test Needs New Latch Plate

Documentation showed the facility received this inspection report on March 10, 2020.

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 October 13, 2020 at 1:45 PM, the Chief Operating Officer (COO) said that the maintenance guy should have had it fixed but didn't and the COO does not know why. It was also noted that the Medical Air Compressor was not repaired as the service technician did not emphasize the urgency of the repair that needed to be done.

Following the document review, the COO made contact with representatives from Medical Technology Associates, Inc. The supervisor from Medical Technology Associates advised the Chief Operating Officer that "the worst one was the CO sensor" and he was going to see if he could find one. The MTA supervisor called back and made a statement that he found a CO sensor; however, he did not have the dew point sensor. He stated that the technician could manually turn on the driers in the system to keep any moisture out. He further stated that the technician could be there around 8:00 PM today. The Chief Operating Officer asked the MTA supervisor to get his service technician on site as soon as possible.

The LSC Inspector of the Kansas State Fire Marshal's office notified the facility/COO at 5:17 PM on October 13, 2020 that the Centers for Medicare & Medicaid Services (CMS) identified these deficiencies as an Immediate Jeopardy (IJ - a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient).

The hospital removed the IJ on October 13, 2020 at 8:04 PM when they submitted a plan to hold all surgeries, procedures, and heart catheterizations until the repairs of the CO sensor, Dew Point monitor, and OR outlets are completed and authorization given.

The plan of removal also included the following:
Medical Technology Associates Service Technician will arrive at Kansas Medical Center at approximately 10:00 PM the evening of October 13, 2020.
The Identified Deficiencies will be repaired and in full compliance.
The Identified Deficiencies include the bad Carbon Monoxide and Dew Point censors and the 7 leaking seals.
Once the repairs are made, Medical Technology Associates will provide the hospital with a full report that documents the corrections.
Once the report is received by the hospital, it will be reported immediately to the Office of the Kansas State Fire Marshal and the Kansas Department of Health and Environment (KDHE).

The surveyor verified the hospital completed the following actions on their plan of removal:

The MTA service technician arrived at approximately 10:00 PM on October 13, 2020 and worked until 4:30 AM installing and calibrating a used CO monitor and sensor and repairing all outlets that failed the pressure test in the OR rooms.

Observation at 11:30 AM October 14, 2020 showed that the MTA service technician successfully installed and calibrated a used Dew Point sensor on the medical air compressor.

Since the MTA service technician made repairs to ensure the CO sensor, Dew Point Censor and OR outlets worked, the hospital was cleared to restart surgeries on October 15, 2020 at 11:20 AM.

The facility is scheduled to receive a combination CO and Dew Point monitor and sensor delivery on Friday October 16, 2020 to be installed on Tuesday October 20, 2020. The facility will send the Office of the Kansas State Fire Marshal and KDHE reports showing the sensors have been installed and calibrated.