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Based on observation, interview, and review of facility documents and policies, it was determined the facility failed to meet the Condition of Participation for Physical Plant and Environment when the facility failed to ensure the routine annual inspection and certification of the facility's medical gas system. The failure to ensure the routine inspection and certification of the medical gas system resulted in an Immediate Jeopardy (represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death) for all 13 currently admitted patients that required, or potentially required, the use of oxygen.

Findings Include:

The facility failed to ensure the piped, medical gas system used throughout the facility was routinely inspected and certified by a medical technology inspector. This deficient practice, which resulted in an Immediate Jeopardy, identified on 12/30/19 at 3:30 PM by a Life Safety Code Inspector (LSCI) with the Kansas State Fire Marshal's Office. The facility removed the Immediate Jeopardy by providing a signed document stating that they would not use the Medical Gas system until it was inspected by a qualified medical gas inspector and by moving all patients to portable oxygen bottles and concentrators. The LSCI confirmed validation of the facility's corrective action and the removal of the immediate jeopardy. (Cross-reference C-0930 and K-907 and K-908).

Based on observation, interview, and review of facility documents and policies, it was determined the facility failed to ensure the routine annual inspection and certification of the facility's medical gas system. The failure to ensure the routine inspection and certification of the medical gas system resulted in an Immediate Jeopardy (represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death) for all 13 currently admitted patients that required, or potentially required, the use of oxygen.


Findings Include:

1. Review of the National Fire Protection Association (NFPA) 101 showed:
Gas and Vacuum Piped Systems Maintenance Program
Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of the American Society for Healthcare Engineering (ASHE) 6030 or 6040.
5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2

2. Review of the following NFPA Standard revealed: An annual review of bulk system capacity shall be conducted to ensure the source system has sufficient capacity. 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.

A periodic testing procedure for nonflammable medical gas and vacuum and related alarm systems shall be
implemented. 5.1.14.4.7 Procedures, as specified, shall be established for the following:

(1) Maintenance program for the medical air compressor supply system in accordance with the manufacturer's recommendations
(2) Facility testing and calibration procedure that ensures carbon monoxide monitors are calibrated at least annually
or more often if recommended by the manufacturer
(3) Maintenance program for both the medical surgical vacuum piping system and the secondary equipment attached to medical surgical vacuum station inlets to ensure the continued good performance of the entire
medical surgical vacuum system
(4) Maintenance program for the WAGD system to ensure performance

Audible and visual alarm indicators shall meet the following requirements:

(1) They shall be periodically tested to determine that they are functioning properly.
(2) Records of the test shall be maintained until the next test is performed.

Medical surgical vacuum station inlet terminal performance, as required in 5.1.12.3.10.4, shall be tested as follows:

(1) On a regular preventive maintenance schedule as determined by the facility maintenance staff
(2) Based on flow of free air (Nl/min or SCFM) into a station inlet while simultaneously checking the vacuum level

3. Review of the following NFPA Standard revealed: 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) LeaksContinued From page 46
K 908

2012 NFPA 99, 5.1.14.2.3.1

Review of the following NFPA Standard revealed: An annual review of bulk system capacity shall be conducted to ensure the source system has sufficient capacity. 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.

A periodic testing procedure for nonflammable medical gas and vacuum and related alarm systems shall be
implemented. 5.1.14.4.7 Procedures, as specified, shall be established for the following:

(1) Maintenance program for the medical air compressor supply system in accordance with the manufacturer's recommendations
(2) Facility testing and calibration procedure that ensures carbon monoxide monitors are calibrated at least annually
or more often if recommended by the manufacturer
(3) Maintenance program for both the medical surgical vacuum piping system and the secondary equipment attached to medical surgical vacuum station inlets to ensure the continued good performance of the entire
medical surgical vacuum system
(4) Maintenance program for the WAGD system to ensure performance

Audible and visual alarm indicators shall meet the following requirements:

(1) They shall be periodically tested to determine that they are functioning properly.
(2) Records of the test shall be maintained until the next test is performed.

Medical surgical vacuum station inlet terminal performance, as required in 5.1.12.3.10.4, shall be tested as follows:

(1) On a regular preventive maintenance schedule as determined by the facility maintenance staff
(2) Based on flow of free air (Nl/min or SCFM) into a station inlet while simultaneously checking the vacuum level
2012 NFPA 99, 5.1.14.4.3 through 5.1.14.4.9

4. Record review on December 30, 2019 by the state agency's life safety code inspector (LSCI), who was performing a routine healthcare survey, observed that the facilities piped medical gas system has not been inspected since it was put into operation in 2011.

5. Staff member B provided the surveyor paperwork form a medial gas vendor which had a calendar date of 2011, Staff member B said the system hasn't been inspected annually since install in 2011.

6. This deficient practice resulted in the LSCI of the Office of the state Fire Marshal notifying the Hospital administration that the Centers for Medicare & Medicaid services (CMS) identified this as an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more of the requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) on 12/30/19 at approximately 3:30 pm. The Immediate Jeopardy was removed by the facility providing a signed document stating that they would not use the Medical Gas system until it was inspected by a qualified medical gas inspector. The facility moved all patients to
portable oxygen bottles and concentrators and had the a medical gas inspection conducted the next morning by qualified personal who approved the system for the medical center to return to normal operating procedures