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Based on observation and staff interview, the facility failed to maintain the medical gas warning alarm system for the immediate care/pre and post operation nursing department of the hospital. This deficient practice of not maintaining the medical gas warning alarm system to this specific area of the hospital could allow undetected variances in the medical gases to occur without immediate alarm notification within this department affecting 42 patients in one of eleven smoke zones. The facility has a capacity of 54 and census of 37 at the time of the survey.

Findings include:

During the routine survey on June 22nd and 23rd, 2017 and follow-up complaint on June 26th, 2017 the following observations were made:

Based on interview during the documentation review on Thursday June 22nd, 2017 the maintenance supervisor acknowledged that the hospital does not have a medical gas maintenance, inspection or testing program in place.

Based on observation on Friday June 23rd, 2017 at 10:59 a.m. in the Immediate Care pre/post op surgery department nurses station the medical gas alarm panel that monitors the oxygen, medical air and vacuum pressures was observed with no display on the panel. When the panel test button was pressed nothing happened. Maintenance Supervisor A stated that he did not know the panel was not working and acknowledged the finding. The main medical gas alarm panel in the intensive care unit was also observed; it was working with no alarms.

Based on observation on Monday June 26th, at 9:30 a.m. the medical gas alarm panel covering the Immediate Care pre/post op surgery department was observed with no display on the panel. Upon interview with the Chief Operating Officer and the Risk Manager (12) surgeries had been scheduled and performed this morning. Upon interview with nursing staff A and nursing staff B at 9:35 a.m. in the Immediate Care department they stated they had not noticed the panel was not working. The Maintenance Supervisor stated that he was going to make some calls and try to find a part; he stated he believed the problem was with the panel power supply.

Based on interview the Risk Manager at 10:15 a.m. stated the Immediate Care nursing staff had begun moving the patients out of the Immediate Care department and into the Intensive Care Unit and was complete at 12:00 p.m. Observation confirmed.

At 12:16 p.m. the Chief Operating Officer and the Risk Manager were notified that the hospital had been placed in "Immediate Jeopardy" status.

Based on observation at 2:35 p.m. on Monday June 26th, 2017 maintenance staff A removed the old power supply box and replaced it with the delivered power supply on the medical gas alert panel. Maintenance staff A reenergized the panel at 2:49 p.m. immediately the digital psi readout and the green high/low pressure indicators began working. The panel was tested and found to be working appropriately effectively abating the immediate jeopardy.

During interview with staff at approximately 3:15 p.m. the Chief Operating Officer stated that he had not been advised that the panel was not working until I had called him at 8:30 a.m. The Maintenance Supervisor was notified the medical gas alarm panel was not functioning three days prior; he had not informed hospital administration or made attempts to correct the system.

Review of the following NFPA Standard revealed: Facilities shall have a routine maintenance program for their piped medical gas and vacuum systems. (NFPA 99) 5.1.15

Review of the following NFPA Standard revealed: All master, area, and local alarm systems used for medical gas and vacuum systems shall include the following:
(1) Separate visual indicators for each condition monitored, except as permitted in 5.1.9.5.2 for local alarms that are displayed on master alarm panels
(2) Visual indicators that remain in alarm until the situation that has caused the alarm is resolved
(3) Cancelable audible indication of each alarm condition that produces a sound with a minimum level of 80 dBAat 0.92 m (3 ft)
(4) Means to visually indicate a lamp or LED failure
(5) Visual and audible indication that the communication with an alarm-initiating device is disconnected
(6) Labeling of each indicator, indicating the condition monitored
(7) Labeling of each alarm panel for its area of surveillance
(8) Reinitiation of the audible signal if another alarm condition occurs while the audible alarm is silenced
(9) Power for master, area alarms, sensors, and switches from the life safety branch of the emergency electrical system.
(10) Power for local alarms, dew point sensors, and carbon monoxide sensors permitted to be from the same essential electrical branch as is used to power the air compressor system
(11) Where used for communications, wiring from switches or sensors that is supervised or protected as required by 517.30(C)(3) of NFPA 70, National Electrical Code, for life safety and critical branches circuits in which protection is any of the following types: (a) Conduit, (b) Free air, (c) Wire, (d) Cable tray and (e) Raceways.
(12) Communication devices that do not use electrical wiring for signal transmission will be supervised such that failure of communication shall initiate an alarm.
(13) Assurance by the responsible authority of the facility that the labeling of alarms, where room numbers or designations are used, is accurate and up-to-date
(14) Provisions for automatic restart after a power loss of 10 seconds (e.g., during generator start-up) without giving false signals or requiring manual reset
(15) Alarm switches/sensors installed so as to be removable (NFPA 99) 5.1.9