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Based on document review, and life safety code (LSC) complaint survey (ASPEN #G2YB21; KS00172910) conducted by the Office of the Kansas State Fire Marshal (OSFM) from 06/01/22 - 06/02/22, the facility failed to ensure that the medical gas warning alarm system equipment is maintained in accordance with the National Fire Protection Association (NFPA) 99 by failing to ensure the carbon monoxide (CO - an odorless, colorless gas, which can cause sudden illness and death) sensor functioned appropriately. This deficient practice 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 based on observations made during a routine inspection of the same facility on 06/01/22.

The facility has 25 certified beds and at the time of the survey had a census of six patients.

On 06/02/22 there were 3 surgeries scheduled.

Review of document titled, "Medical (Med) Gas Report" dated 05/12/21, showed the following:
1) No Ground Rod
2) Liquid Level Gauge not hooked up
3) Emergency Oxygen supply Connection is not installed
4) Liquid level gauge not wired has ball

The facility removed the Immediate Jeopardy on 06/02/22 prior to the survey exit by implementing the following actions:

06/01/22 3:57 PM Facility placed in Fire Watch

06/01/22 4:00 PM The CFO (Chief Financial Officer), Surgery Staff and maintenance staff were advised that all patients would need to be removed from the liquid oxygen tank system until repairs could be made and documented. Hospital is able to continue surgeries Thursday morning with patients being on Compressed O2 (Cylinders).

06/01/22 4:16 PM The Director of Facilities contacted Technician Staff C from Medical Technology Associates (MTA) via phone and provided him information on citations received from the Fire Marshal. Technician C arrived to Lindsborg Community Hospital at 5:57 PM. Tecnician C and a partner from MTA completed the install of a liquid level gauge on the bulk oxygen tank and live tested to make sure it was working properly. Pestinger's Electrician to come to finish conduit.

06/01/22 05:21 PM The Technician at Air Gas was contacted via phone by the Director of Facilities on 06/01/22 in regards to the ground rod. The Technician provided instructions on where to obtain the ground rod and Staff F, Maintenance went to American Electric in Salina, KS and received the 10 ft. ground rod at 5:18 PM on 06/01/22. Staff F arrived back at Lindsborg Community Hospital and the Technician with air gas had already arrived at 6:26 PM. The Technician gave verbal instructions to the Director of Facilities on how to install the ground rod. At that time, the Director of Facilities installed the ground rod following The Technician's instructions. The Director of Facilities completed placement of the ground rod at approximately 8:00 PM. The Technician with Air Gas was present during the entire installation process of the ground rod.

06/02/22 10:05 AM Pestinger's Electrician arrives at Lindsborg Community Hospital at 10:05 AM and completes conduit.

06/02/22 11:32 AM The Immediate Jeopardy template was delivered by the OSFM Inspector to the Executive Assistant.

06/02/22 11:50 AM The Executive Assistant delivered the IJ Template with signatures and the plan of removal to survey staff.

06/02/22 3:55 PM The Chief Financial Officer (CFO) was notified that the deficiencies have not been abated and the hospital must continue to use compressed oxygen on all patients, and during all surgeries until the OSFM has received documentation that all four (4) deficiencies have been successfully removed.

After further review of the documentation, it was determined that the facility removed the IJ with the plan of removal submitted at 11:50 AM on 06/02/22, The Centers for Medicare & Medicaid Services (CMS) approved the plan at 2:17 PM on 06/02/22.

Findings Include:

The facility failed to maintain medical gas warning alarm bulk liquid oxygen storage for the facility. (Refer to A709)

See LSC complaint survey findings (KS00172910; ASPEN #G2YB21 - K904) for further details.

Based on observation, staff interview, record review and life safety code (LSC) complaint survey findings(KS00172910; ASPEN #G2YB21) the facility failed to maintain medical gas warning alarm bulk liquid oxygen storage for the facility. This deficient practice has the potential for undetected variances in the medical gases to occur without immediate alarm notification within this department affecting 4 patients in 2 of four smoke zones.

Findings Include:

The facility has 25 certified beds and at the time of the survey had a census of 6 patients. On June 2, 2022 there were 3 surgeries scheduled.

The fire alarm control panel is located in the employee entrance hallway on the south wall. There is one annunciator panel in the Operating room, and one at the nurses station.

During the routine survey on 06/01/22 and follow up complaint on 06/02/22 the following observations were made:

Review of document titled, "Medical (Med) Gas Report" dated 05/12/21, showed the following:
1) No Ground Rod
2) Liquid Level Gauge not hooked up
3) Emergency Oxygen supply Connection is not installed
4) Liquid level gauge not wired has ball

06/01/22

3:55 PM Informed CFO, Surgery Staff and maintenance staff of Immediate Jeopardy Status.

3:57 PM Facility placed in Fire Watch
4:00 PM The CFO (Chief Financial Officer), Surgery Staff and maintenance staff were advised that all patients would need to be removed from the liquid oxygen tank system until repairs could be made and documented. Hospital is able to continue surgeries Thursday morning with patients being on Compressed O2 (Cylinders).

4:16 PM The Director of Facilities contacted Technician Staff C from Medical Technology Associates (MTA) via phone and provided him information on citations received from the Fire Marshal. Technician C arrived to Lindsborg Community Hospital at 5:57 PM. Tecnician C and a partner from MTA completed the install of a liquid level gauge on the bulk oxygen tank and live tested to make sure it was working properly. Pestinger's Electrician to come to finish conduit.

05:21 PM The Technician at Air Gas was contacted via phone by the Director of Facilities on 06/01/22 in regards to the ground rod. The Technician provided instructions on where to obtain the ground rod and Staff F, Maintenance went to American Electric in Salina, KS and received the 10 ft. ground rod at 5:18 PM on 06/01/22. Staff F arrived back at Lindsborg Community Hospital and the Technician with air gas had already arrived at 6:26 PM. The Technician gave verbal instructions to the Director of Facilities on how to install the ground rod. At that time, the Director of Facilities installed the ground rod following The Technician's instructions. The Director of Facilities completed placement of the ground rod at approximately 8:00 PM. The Technician with Air Gas was present during the entire installation process of the ground rod.

06/02/22

10:05 AM Pestinger's Electrician arrives at Lindsborg Community Hospital at 10:05 AM and completes conduit.

11:32 AM The Immediate Jeopardy template was delivered by the OSFM Inspector to the Executive Assistant.

11:50 AM The Executive Assistant delivered the IJ Template with signatures and the plan of removal to survey staff.

3:55 PM The Chief Financial Officer (CFO) was notified that the deficiencies have not been abated and the hospital must continue to use compressed oxygen on all patients, and during all surgeries until the OSFM has received documentation that all four (4) deficiencies have been successfully removed.

3:57 PM The Fire Watch has been implemented a Fire watch that they must continue until the violations noted on the medical gas ( Oxygen ) report have been corrected.

After further review of the documentation, it was determined that the facility removed the IJ with the plan of removal submitted at 11:50 AM on 06/02/22, The Centers for Medicare & Medicaid Services (CMS) approved the plan at 2:17 PM on 06/02/22.