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Based on document review and staff interview, the facility did not ensure timely repair for the presence of nitrous oxide detected in the 4D Units (Maternity/Newborn), and nitrous oxide leaks identified in the Datex-Ohmeda anesthesia machines in the operating rooms. This placed patients and staff at risk for harm.


Findings:

Review of the document, "Assay Technology Lab Work (Order: 2018120039)," dated 12/4/18 documented concentrations of Nitrous Oxide on 4D Unit as follows:
· 4D Clerk Front Station Nurses Station = 0.80 RptLmt (Reporting Limit=0.54)
· 4D Front = 0.74 Rpt/Lmt (Reporting Limit=0.53)
· 4D Floor = 0.60 Rpt/Lmt (Reporting Limit=0.53)
· Air Handler 12 = 1.8 Rpt/Lmt (Reporting Limit=0.53)
· Air Handler 12 IAQ Testing =1.4 Rpt/Lmt (Reporting Limit=0.52)


Review of the document "Waste Gas Analysis" dated 12/11- 12/13/18, documented that some of the Datex-Ohmeda anesthesia machines had leaks exceeding 30 PPM (Parts Per Million) at some Nitrous Oxide outlets. This indicated O-rings were worn down and needed to be replaced. The facility had the deficiency corrected by a certified outside vendor by January 5, 2019.
This finding was acknowledged with the presence of Staff Dd, Associate Administrator.

On 1/9/19 at 3:00 PM, Staff Cc, Director of Safety Services was interviewed. Staff Cc stated that the facility had identified the presence of nitrous oxide in 4D on 12/4/18. Staff Cc also stated that the nitrous oxide leaks identified on 12/11-12/13/18 were repaired with 100% replacement of all nitrous oxide outlet O-rings on 1/4/19.


There was a gap of thirty one (31) days from 12/4/18 to 1/4/19 when nitrous oxide O-rings were replaced.
The facility did not ensure that a timely repair was conducted for the presence of nitrous oxide leaks. This placed patients' and staff at risk for harm.

Based on document review and staff interview, the facility failed to follow manufacturer's Directions for Use (DFU) of the anesthesia machines. Failure to follow the manufacturer's DFU could result in equipment malfunction and/or failure and negatively impact the safety and wellbeing of the patients.

Findings include:

During review of the document "Waste Gas Analysis," dated 12/11- 12/13/18 at 01/09/2018, it was noted that some of the Datex-Ohmeda anesthesia machine O-Rings were worn down, resulting in leaks exceeding 30 ppm at some Nitrous Oxide outlets.

The manufacture's user maintenance of the Datex-Ohmeda anesthesia machine recommend the replacing of external O-rings annually. There is no documented evidence of replacement of O-rings during the Preventive Maintenance of Anesthesia machines. Therefore, it was determined that the facility failed to replace the O-rings in a timely manner which led to the leaks of some Nitrous oxide outlets, exposing patients and staff to nitrous oxide.

This finding was identified in the presence of Staff Cc, Director of Safety Services and was brought to the attention of facility administrators during the exit conference on 01/10/2019.