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Based upon observation, document review, and staff interview the facility is not inspecting and maintaining their medical air gas system in compliance with National Fire Protection Association (NFPA) 99. This deficient practice could prevent the medical air gas system from working properly in the event of an emergency. This deficient practice affects the emergency room and approximately 3 patients per day. The facility has a capacity of 25 with a census of 15 at the time of this survey.

Findings include:

K902. Document review conducted on the morning of 7/8/2022 revealed multiple deficiencies involving Medical Gas (suction). The Airgas report from January 25, 2022 and received on February 7, 2022 stated the following.

There is no documentation of repair or replacement of the following (10) deficiencies between February 7, 2022 and July 8, 2022.

1. Lag alarm is not installed, present and functioning at local alarm panel.
2. Local alarm is not tied into master alarm panel indicating a malfunction.
3. Automatic alternation is not operating correctly.
4. Vacuum gauge is not present at receiver.
5. Receiver cannot be isolated from system.
6. Receiver does not have a manual drain.
7. Vacuum exhaust is not located 10 feet from any door, window, air intake, other building opening or places of public assembly.
8. Vacuum exhaust discharge is not turned down.
9. Vacuum exhaust discharge is not screened.
10. Vacuum alarm visual alarm failure.
11. COMMENTS: Vacuum sensor needs to be replaced. Not reading accurately.

The Immediate Jeopardy was successfully abated at 3:55 p.m. on 7/8/22.

Staff M1 and M2 were present and acknowledged the findings.

NFPA 99. 5.1.9.2* Master Alarms. A master alarm system shall be provided to monitor the operation and condition of the source of supply, the reserve source (if any), and the pressure in the main lines of each medical gas and vacuum piping system.
5.1.9.2.1 The master alarm system shall consist of two or more alarm panels located in at least two separate locations, as follows:
(1) One master alarm panel shall be located in the office or work space of the on-site individual responsible for the maintenance of the medical gas and vacuum piping systems.
(2) In order to ensure continuous surveillance of the medical gas and vacuum systems while the facility is in operation, the second master alarm panel shall be located in an area of continuous observation (e.g., the telephone switchboard, security office, or other continuously staffed location).

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 fails to ensure that the suction with be available for full and instant use in an emergency. The deficient practice affects approximately 3 patients per day in the emergency room. All surgeries have been allowed to continue with the use of bottled oxygen and portable suction.

The facility has a capacity of 25 with a census of 15 at the time of this survey.

Findings Include:

K908. Document review conducted on the morning of 7/8/2022 revealed multiple deficiencies involving Medical Gas (suction). The Airgas report from January 25, 2022 and received on February 7, 2022 stated the following.

1. Lag alarm is not installed, present and functioning at local alarm panel.
2. Local alarm is not tied into master alarm panel indicating a malfunction.
3. Automatic alternation is not operating correctly.
4. Vacuum gauge is not present at receiver.
5. Receiver cannot be isolated from system.
6. Receiver does not have a manual drain.
7. Vacuum exhaust is not located 10 feet from any door, window, air intake, other building opening or places of public assembly.
8. Vacuum exhaust discharge is not turned down.
9. Vacuum exhaust discharge is not screened.
10. Vacuum alarm visual alarm failure.
11. COMMENTS: Vacuum sensor needs to be replaced. Not reading accurately.

There is no documentation provided for correction of these deficiencies.

11:04 a.m. During document review, several violations were discovered relating to the vacuum systems for medical gas.
1:16 p.m. Facility was alerted that the issue is serious and in need of immediate attention.
2:14 p.m. Vendor contacted facility regarding coming out to work on the system. Facility was informed that the deficiencies are in need of immediate action.
2:37 p.m. Vendor contacted facility for pictures from the system so that they can check on the parts, and if they have them, head towards the facility to start working on the system.
2:52 Facility sent the pictures to MTA and they are checking on availability of parts and will call back.
3:42 The facility is informed these deficiencies result in an IJ level.
4:09 p.m. The facility is implementing portable suction and bottled oxygen in the emergency room until the medgas system repairs are completed.

The facility was notified at 3:42 p.m. on July 8, 2022 that that these deficiencies represent an Immediate Jeopardy.

The Immediate Jeopardy was successfully abated at 3:55 p.m. on 7/8/22.

Review of the following NFPA Standard revealed: 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.

NFPA 99. 5.1.9.2* Master Alarms. A master alarm system shall be provided to monitor the operation and condition of the source of supply, the reserve source (if any), and the pressure in the main lines of each medical gas and vacuum piping system.
5.1.9.2.1 The master alarm system shall consist of two or more alarm panels located in at least two separate locations, as follows:
(1) One master alarm panel shall be located in the office or work space of the on-site individual responsible for the maintenance of the medical gas and vacuum piping systems.
(2) In order to ensure continuous surveillance of the medical gas and vacuum systems while the facility is in operation, the second master alarm panel shall be located in an area of continuous observation (e.g., the telephone switchboard, security office, or other continuously staffed location).