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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) in the oxygen. The deficient practice affects all patients throughout Building 4. The facility has 760 certified beds and at the time of the survey had a census of 377 patients. The hospital had 52 patients scheduled for surgery on June 27, 2022 and 35 patients scheduled for surgery on June 28, 2022. All surgeries have been allowed to continue with the use of bottled oxygen and portable suction.

Findings Include:

Documentation review during a routine survey on June 27, 2022 of the annual Medical (Med) Gas Testing Report from Medical Technology Associates (MTA) dated 5/16/22-5/19/22 showed the following deficiencies:

1. Low battery on PLC inside control cabinet (Digital readout) needs to be replaced in NICU (neonatal intensive care unit) A level Building 6 basement.

2. Building 4 "M" level CO (carbon monoxide) sensor was not reaching 10 ppm when testing. Sensor needs to be replaced.

3. Oxygen alarm visual alarm failure in vascular holding.

4. Oxygen alarm audible alarm failure in vascular holding.

5. Medical air alarm visual alarm failure in vascular holding.

6. Medical air alarm audible alarm failure in vascular holding.

7. COMMENTS: AREA ALARM HAS NO POWER. RECOMMEND REPLACING POWER SUPPLY.

8. Vacuum ports in the following areas have deficiencies and are not working as designed: ER (emergency room) rooms 1-12, 14, Xray, and CCU (coronary care unit) procedure rooms 20-26, and OR (operating room) rooms 4, 6, 12, 15, and 20, Floor 3 Tee (transesophageal echocardiogram) room, 6-122 C-Section (cesarean section) Room and 6-123 C-Section room.

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

During staff interview on June 27, 2022 at 2:07 p.m. the Director of Environmental safety stated that the deficiencies had been acknowledged and a bid was requested and accepted for repair.

Following document review, the Market Director of Plant Operations and Facilities Management made contact with a contractor for repairs at 4:52 p.m. The contractor arrived onsite at 9:16 p.m. and began working on the system.

The facility was notified at 11:15 a.m. on June 28, 2022 that that these deficiencies represent an Immediate Jeopardy.

The hospital abated the immediate jeopardy on June 29, 2022 at 8:20 a.m. when the air gas documentation was reviewed and verified. The hospital Chief Operating Officer was notified that the hospital was released from fire watch.

Review of the following NFPA Standard revealed: Medical Air Systems shall have air quality monitoring for their piped medical air systems. (NFPA 99) 5.1.3.6.3.14

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