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Based upon a review of records, observation, and staff interview, the facility fails to assure that Gas and Vacuum Piped Systems are tested and maintained in accordance with NFPA 99. The deficient practice does not assure that procedures and testing methods are established through risk assessment, affecting all patients, visitors and staff in 10 of 14 smoke zones. The facility has a capacity of 101 patients with a census of 29 at the time of this complaint inspection:

During the survey conducted on 05/23/2022, between 1:00 p.m. and 3:30 p.m., it is observed:

-- 1. Review of records revealed that the facility was not properly documenting dew points for the compressor and did not have a policy for reporting procedures if out of range.

-- 2. Observation of the vacuum exhaust system and boiler exhaust system revealed that outlets for both exhaust systems are on the same horizontal plane, creating a potential for one system to intake from the other. The facility has reviewed and evaluated exhaust systems with no adjustments complete at the time of this survey.

-- 3. The vacuum alarm system and the dew point sensor on the medical air system are not tied into the Master alarm panel. The local alarms for the med gas systems are functioning.

-- 4. Nitrogen has been turned off in surgical suite operating room 4. No policy or procedure in place to assure alternate location or alternate source of Nitrogen for treatment of patients requiring Nitrogen.

-- 5. Med air valve gauge is not working but alarms are working. Interview with facility staff reveals that that configuration of the piping is incorrect, with placement of the gauge in the wrong place. No steps have been taken to assure to piping and gauges are correctly configured.

Staff M1 and Staff M2 were present and acknowledged the findings.

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Based upon a review of records and staff interview, the facility fails to assure that personnel concerned with the application, maintenance and handling of medical gasses are properly trained in accordance with NFPA 99. The deficient practice does not assure that procedures are established through risk assessment, affecting all patients, visitors and staff in 10 of 14 smoke zones. The facility has a capacity of 101 patients with a census of 29 at the time of this complaint inspection:

During the survey conducted on 05/23/2022, between 1:00 p.m. and 3:30 p.m., review of records reveals:

-- 1. The facility does not have a policy and procedure in place to assure that staff are educated on the importance of immediately reporting medical gas alarms in their area; ability to identify which gauges are not working; ability to identify zone valves while the facility is in process of working with vendor for resolution.

-- 2. The facility does not have a policy and procedure in place to assure that patients requiring treatment with Nitrogen must have the procedure in an alternate operating room with Nitrogen or provide an alternate source of Nitrogen when piped-in Nitrogen is turned off in surgical suite operating room 4.

Staff M1 and Staff M2 were present and acknowledged the findings.
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