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Based on document review and review of the Life Safety Code complaint investigation findings (ASPEN #E90U21; KS00172816), 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 hospital submitted a credible plan of IJ removal on 06/28/22 at 2:28 PM that included:

On 06/27/22:

2:28 PM - Plant Operations Director communicated with Medical Technology Associates
(MTA) and placed request to have repairs on 2022 Annual Med Gas Report made next day 6/28/2022.

2:45 PM - Plant Operations Director communicated with MTA to request repairs/replacements be made to Med Gas deficiencies noted on 2022 report be completed tonight (6/27/22). MTA confirms they are en route from Kansas City.

5:38 PM - Plant Operations Director received notification from State Fire Marshall that Wesley Medical Center was being placed on Fire Watch.

6:18 PM - COO, VP Operations, Plant Ops Director, Quality Manager received clarification regarding Fire Watch and areas needing immediate action regarding Med Gas/Oxygen and Vacuum System failures from the Fire Marshall.

6:20 PM - Hospital Incident Command System established by Chief Operating Officer and Safety Officer. The following actions were taken:
- Vascular Holding identified to be unoccupied and determined to remain unoccupied. Hourly fire watch initiated.
- Number of patients in Building 4 on supplemental oxygen identified, cylinders distributed by respiratory therapy, and patients transitioned to cylinder oxygen use. Hourly fire watch initiated.
- Portable suction devices distributed to the CCU, Emergency Department, and Birthcare Center C-section Suites. - - Operating Rooms 4, 6, 12, 15, 20 ceased to utilize wall suction and performed necessary operations with portable Neptune suction . Fire Watch initiated.
- Patients in affected CCU rooms requiring suct ion were relocated to unaffected rooms.
- All laboring patients in the Birthcare Center (associated with 6-122 and 6-123 (C-section Suites) were moved to main campus Labor and Delivery. Portable suction devices were distributed to Birthcare Center for use in the event of an emergency. Fire Watch Initiated
- TEE treadmill room was unoccupied at time of notice. No patients were scheduled in this room on 6/28/22. Procedures will be performed in an unaffected Cath Lab if necessary. Fire Watch initiated.
- Portable Suction device delivered to affected X-ray area. Fire Watch init iated.
- Additional rental suction units obtained and addit iona l oxygen cylinders obtained.
- Facility initiated Adult Progressive Care Unit, Telemetry, Adult ICU, and General pediatric t ransfer closures to conserve resources.

9:16 PM - Two MTA technicians arrived on site and initiated repairs.

Repairs for the following items listed on the IJ template were completed and submitted to the OSFM at 2:28 AM on 6/28/22.
1. Low battery on PLC in side control cabinet NICU A Level Building 6
2. Building 4 "M" level CO (carbon monoxide) sensor
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 audible alarm failure in vascular holding
7. Power Supply in Vascular holding area alarm
8. Vacuum ports in ER rooms 1-12 and 14; X-ray; CCU procedure rooms 20-26 , and OR 4, 15, TEE treadmill room, C-section room 6-122 and 6-123
9. The following areas are pending repair from MTA. MTA is scheduled to complete repairs the remaining repairs in OR 6, 12, 20 on 6/28/22.
Hourly Fire Watch continues in all areas at this time.

The hospital removed the IJ on 06/29/22 at 8:20 AM prior to the survey exit.

Findings Include:

The hospital failed to meet the applicable provisions of the current Life Safety Code (LSC) when they failed to have repairs completed immediately after receipt of their annual "Medical (Med) Gas Report" showing issues with the CO Sensor and multiple alarms for Oxygen, Medical Air, and a Power Supply. (Refer to Tag A-0709).

Refer to the Life Safety Code findings (ASPEN #E90U21) dated 06/29/22 for further details.

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:

Review of documentation titled, "Medical (Med) Gas Testing Report," dated 05/16/22 - 05/19/22 during a routine inspection of the State Fire M/rshal (OSFM) on 06/27/22 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.

The facility did not provide any evidence or documentation to show that they had repaired any of the broken sensors or outlets since receiving the Med Gas inspection report.

During a staff interview on 06/27/22 at 2:07 PM, the Director of Environmental Safety stated that they were aware of the deficiencies and had requested an accepted a bid for repairs.

At 4:52 PM on 06/27/22, the Director of Plant Operations and Facilities Management made contact with a contractor for repairs. The contractor arrived onsite at 9:16 p.m. and began working on the system.

The facility was notified at 11:15 AM on 06/28/22 that that these deficiencies represent an Immediate Jeopardy.

The hospital removed the IJ on 06/29/22 at 08:20 AM when the contractor provided documentation that they had completed all of the repairs. The OSFM verified the completed repairs and the hospital Chief Operating Officer was notified that the hospital was released from fire watch.

Refer to the Life Safety Code findings (ASPEN #E90U21) dated 06/29/22 for further details.