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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) and unacceptable levels of moisture in the medical air. The deficient practice affects all patients throughout the hospital. The facility has 58 certified beds and at the time of the survey had a census of 38 patients. The hospital had twenty patients scheduled for surgery on October 14, 2020 and twenty seven patients scheduled for surgery on October 15, 2020. These surgeries were canceled due to the noncompliance.

Findings Include:

Documentation review during a routine survey on October 13, 2020 of the annual Medical (Med) Gas Testing Report from Medical Technology Associates (MTA) dated March 2, 2020 showed the following deficiencies:

1) Medical Gas Compressor - Failed - Bad Carbon Monoxide (CO - a colorless, odorless, and tasteless flammable gas that can be toxic) Sensor.

2) Medical Gas Compressor - Failed - Bad Dew Point (the dew point is the lowest temperature that allows water vapor to remain in a gas without condensing to a liquid state) Sensor.

3) Seven outlets for the Operating Room's (OR's) vacuum system failed:
OR2 - Outlet 2 - Leaking - Failed - Operational Pressure Test
OR2 - Outlet 3 - Leaking - Failed - Operational Pressure Test
OR3 - Outlet 4 - Leaking - Failed - Operational Pressure Test
OR4 - Outlet 5 - Leaking - Failed - Operational Pressure Test
OR6 - Outlet 6 - Failed Operational Pressure Test - Needs New Latch Plate
OR6 - Outlet 7 - Failed Operational Pressure Test - Needs New Latch Plate
OR6 - Outlet 8 - Failed Operational Pressure Test - Needs New Latch Plate

The facility received this inspection report on March 10, 2020.

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

During an interview on October 13, 2020 at 1:45 PM, the Chief Executive Officer (COO) said that the maintenance guy should have had it fixed but didn't and the COO does not know why. It was also noted that the Medical Air Compressor was not repaired as the service technician did not emphasize the urgency the repair needed to be done.

Following the document review, the Chief Operating Officer (COO) made contact with representatives from Medical Technology Associates, Inc. The supervisor from Medical Technology Associates advised the Chief Operating Officer that "the worst one was the CO sensor" and he was going to see if he could find one. The MTA supervisor called back and made a statement that he found a CO sensor; however, he did not have the dew point sensor. He stated that the technician could manually turn on the driers in the system to keep any moisture out. He further stated that the technician could be there around 8:00 PM today. The Chief Operating Officer asked the MTA supervisor to get his service technician on site as soon as possible.

The facility/COO were notified at 5:17 PM on October 13, 2020 that that these deficiencies represent an Immediate Jeopardy.

The hospital removed the IJ on October 13, 2020 at 8:04 PM when they submitted a plan to hold all surgeries, procedures, and heart catheterizations until the repairs of the CO sensor, dew point monitor, and OR outlets are completed and authorization given.

The plan of removal also included the following:
Medical Technology Associates Service Technician will arrive at Kansas Medical Center at approximately 10:00 P.M. the evening of October 13, 2020.
The Identified Deficiencies will be repaired and in full compliance.
The Identified Deficiencies include the bad Carbon Monoxide and Dew Point censors and the 7 leaking seals.
Once the repairs are made, Medical Technology Associates will provide the hospital with a full report that documents the corrections.
Once the report is received by the hospital, it will be reported immediately to the Kansas State Fire Marshal Office and the Kansas Department of Health and Environment (KDHE).

The surveyor verified the hospital completed the following actions on their plan of removal:

The MTA service technician arrived at approximately 10:00 PM on October 13, 2020 and worked until 4:30 AM installing and calibrating a used CO monitor and sensor and repairing all outlets that failed the pressure test in the OR rooms.

Observation at 11:30 AM October 14, 2020 showed that the MTA service technician successfully installed and calibrated a used Dew Point sensor on the medical air compressor.

Since the MTA service technician made repairs to ensure the CO sensor, Dew Point Censor and OR outlets worked, the hospital was cleared to restart surgeries on October 15, 2020 at 11:20 AM.

The facility is scheduled to receive a combination CO and Dew Point monitor and sensor delivery on Friday October 16, 2020 to be installed on Tuesday October 20, 2020. The facility will send the Kansas State Fire Marshal Office and KDHE reports showing the sensors have been installed and calibrated.


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