HospitalInspections.org

This STANDARD is not met as evidenced by:
Based upon record review and staff interviews on 5/17/2016 between approximately 0830 and 1230 hours the facility failed to properly maintain the medical gas system in the facility in accordance with NFPA 99. This could result in the system not functioning as designed to provide medical air on demand which could potentially endanger the patients within the facility.

The findings include, but are not limited to: the facility has failed to maintain their medical air compressors in accordance with NFPA 99 4-3.1.1.9 (c)-maintaining two or more medical air compressors to avoid loss of pressure in the system.

Interviews were conducted with the Director of Operations and Maintenance, the Manager of Program Operations, the Utilities Shutdown Manager, Accreditation Manager, the Assistant Administrator of Safety and the Director of Safety. Record reviews were conducted of statements made by the Associate Medical Director of the NICU and of the hospital's UHC Safety Intelligence Q/R reports.

It was determined that on 7-15-15 around 0330 hours; the Equipment branch Automatic Transfer Switch for the Mountlake Tower was disconnected for planned maintenance. The facility had followed policy and procedures and had notified all affected departments. With the ATS shutoff for the tower, the Medical Air Compressor-SA was shutoff. Facility maintenance staff believed that another Med Air compressor, SW, would compensate for the loss of air generator by Med Compress-SA. Staff did not realize that the Control Valve for Med Air Compressor-SW in the South West Basement mechanical room was shut, keeping any air produced by the Compressor-SW from supplying the Med Air system throughout the tower. Med Air pressure dropped for approximately 10-15 minutes until the Area Med Gas Alarms in the NICU started alarming. Staff determined there was a drop in Medical Air pressure and the Equipment Branch ATS for the Mountlake Tower was brought back online at approximately 0401 hours on 7/15/15.

According to statements made during interviews and the review of the Q/R reports, 6 infants were determined to be at risk of ocular damage due to receiving 100% oxygen during the loss of medical air pressure. Upon an internal investigation conducted by the hospital and according to written statements made by the Associate Medical Director of the NICU, all affected patients were examined and were determined to have no injuries due to receiving the oxygen saturation, and have since been discharged.

This STANDARD is not met as evidenced by:
Based upon record review and staff interviews on 5/17/2016 between approximately 0830 and 1230 hours the facility failed to properly maintain the medical gas system in the facility in accordance with NFPA 99. This could result in the system not functioning as designed to provide medical air on demand which could potentially endanger the patients within the facility.

The findings include, but are not limited to: the facility has failed to maintain their medical air compressors in accordance with NFPA 99 4-3.1.1.9 (c)-maintaining two or more medical air compressors to avoid loss of pressure in the system.

Interviews were conducted with the Director of Operations and Maintenance, the Manager of Program Operations, the Utilities Shutdown Manager, Accreditation Manager, the Assistant Administrator of Safety and the Director of Safety. Record reviews were conducted of statements made by the Associate Medical Director of the NICU and of the hospital's UHC Safety Intelligence Q/R reports.

It was determined that on 7-15-15 around 0330 hours; the Equipment branch Automatic Transfer Switch for the Mountlake Tower was disconnected for planned maintenance. The facility had followed policy and procedures and had notified all affected departments. With the ATS shutoff for the tower, the Medical Air Compressor-SA was shutoff. Facility maintenance staff believed that another Med Air compressor, SW, would compensate for the loss of air generator by Med Compress-SA. Staff did not realize that the Control Valve for Med Air Compressor-SW in the South West Basement mechanical room was shut, keeping any air produced by the Compressor-SW from supplying the Med Air system throughout the tower. Med Air pressure dropped for approximately 10-15 minutes until the Area Med Gas Alarms in the NICU started alarming. Staff determined there was a drop in Medical Air pressure and the Equipment Branch ATS for the Mountlake Tower was brought back online at approximately 0401 hours on 7/15/15.

According to statements made during interviews and the review of the Q/R reports, 6 infants were determined to be at risk of ocular damage due to receiving 100% oxygen during the loss of medical air pressure. Upon an internal investigation conducted by the hospital and according to written statements made by the Associate Medical Director of the NICU, all affected patients were examined and were determined to have no injuries due to receiving the oxygen saturation, and have since been discharged.