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Based on observation, staff interview, record review and life safety code (LSC) complaint survey findings(KS00158092; ASPEN #W95121), the facility failed to ensure that the medical gas warning alarm system equipment is maintained and inspected in accordance with the National Fire Protection Association (NFPA) 99 by failing to ensure the carbon monoxide (CO - an odorless, colorless gas, which can cause sudden illness and death) sensor in room 807 functioned appropriately. This deficient practice has the potential to result in failure to notify master alarm panel #1 near the maintenance office and master alarm panel #2 at the main nurses' station of variances in the medical gases.

This resulted in an Immediate Jeopardy level (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) and could adversely affect all patients in all four of four smoke zones using or receiving piped in medical gases from the bulk medical system throughout, which includes the operating room (OR), emergency department (ED) and all patient treatment areas.


Findings Include:


Document review on 11/23/20 of the annual medical gas systems report provided to the facility on 11/18/20 showed the following:

The CO sensor in Room 807 on the decadent air dryer that is connected to the compressor is bad and did not alarm during the 11/11/20 inspection. This has the potential to result in failure to notify master alarm panel #1 near the maintenance office and master alarm panel #2 at the main nurses' station.

The facility currently has 3 patients on continuous oxygen per nasal cannula and has the potential to see patients in the emergency department that need oxygen and/or to admit additional patients requiring oxygen.

Interview with the Director of Nursing on 11/23/20 at 1:30 PM; she indicated that the only procedures performed in the OR are endoscopy or cataract. She indicated that there were endoscopy and cataract procedures performed in the OR the week prior to the survey with five endoscopy or cataract surgeries scheduled for December 3, as well as two endoscopy or cataract procedures scheduled on December 7 and two on December 9.

The Facility Maintenance Director (FMD) was notified on 11/23/20 at 5:44 PM that this deficiency constitutes 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). The FMD sent the plan to remove the IJ by taking the following actions: On 11/23/20 at 3:09 PM, the DON had preemptively emailed staff, directing them not to use the oxygen ports from the piped in med gas system and to use portable praxair oxygen cylinders exclusively and the DON emailed the oxygen supplier to request additional cylinders until the bulk system is available to use again. The FMD confirmed at 5:44 PM that the med gas vendor would be onsite Wednesday 11/25/20 to make repairs and to recertify the med gas system.

In Review of the following standard; 2012 NFPA 99...
(2) Carbon monoxide shall be monitored and shall activate a local alarm when the CO level exceeds 10 ppm. [See 5.1.9.5.4(2).]
(3) Dew point and carbon monoxide monitors shall activate their individual monitor's signal at the alarm panels where their signals are required when their power is lost

See C-0930 and LSC complaint survey findings (KS00158092; ASPEN #W95I21 - K908) for further details.

Based on observation, staff interview, record review and life safety code (LSC) complaint survey findings(KS00158092; ASPEN #W95121), the facility failed to ensure that the medical gas warning alarm system equipment is maintained and inspected in accordance with the National Fire Protection Association (NFPA) 99 by failing to ensure the carbon monoxide (CO - an odorless, colorless gas, which can cause sudden illness and death) sensor in room 807 functioned appropriately. This deficient practice has the potential to result in failure to notify master alarm panel #1 near the maintenance office and master alarm panel #2 at the main nurses' station of variances in the medical gases and could adversely affect all patients in all four of four smoke zones using or receiving piped in medical gases from the bulk medical system throughout, which includes the operating room (OR), emergency department (ED), and all patient treatment areas.


Findings Include:


Document review on 11/23/20 of the annual medical gas systems report provided to the facility on 11/18/20 showed the following:

The CO sensor in Room 807 on the decadent air dryer that is connected to the compressor is bad and did not alarm during the 11/11/20 inspection. This has the potential to result in failure to notify master alarm panel #1 near the maintenance office and master alarm panel #2 at the main nurses' station.

The facility currently has 3 patients on continuous oxygen per nasal cannula and has the potential to see patients in the emergency department that need oxygen and/or to admit additional patients requiring oxygen.

Interview with the Director of Nursing on 11/23/20 at 1:30 PM; she indicated that the only procedures performed in the OR are endoscopy or cataract. She indicated that there were endoscopy and cataract procedures performed in the OR the week prior to the survey with five endoscopy or cataract surgeries scheduled for December 3, as well as two endoscopy or cataract procedures scheduled on December 7 and two on December 9.

The Facility Maintenance Director (FMD) was notified on 11/23/20 at 5:44 PM that this deficiency constitutes 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). The FMD sent the plan to remove the IJ by taking the following actions: On 11/23/20 at 3:09 PM, the DON had preemptively emailed staff, directing them not to use the oxygen ports from the piped in med gas system and to use portable praxair oxygen cylinders exclusively and the DON emailed the oxygen supplier to request additional cylinders until the bulk system is available to use again. The FMD confirmed at 5:44 PM that the med gas vendor would be onsite Wednesday 11/25/20 to make repairs and to recertify the med gas system.

In Review of the following standard; 2012 NFPA 99
5.1.3.6.3.14 Medical Air Systems shall have air quality monitoring for their piped medical air systems.
Review of the following NFPA Standard revealed: Medical air quality shall be monitored downstream of the medical air regulators and upstream of the piping system as follows:
(1) Dew point shall be monitored and shall activate a local alarm and all master alarms when the dew point at system delivery pressure exceeds +2°C (+35°F).
(2) Carbon monoxide shall be monitored and shall activate a local alarm when the CO level exceeds 10 ppm. [See 5.1.9.5.4(2).]
(3) Dew point and carbon monoxide monitors shall activate their individual monitor's signal at the alarm panels where their signals are required when their power is lost


See LSC complaint survey findings (KS00158092; ASPEN #W95I21 - K908) for further details.