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Based on document review and Life Safety Code complaint investigation findings (KS00117589; ASPEN #OP2E21), the Hospital failed to meet the applicable provisions of the current Life Safety Code (LSC) when they failed to maintain the medical gas warning alarm system for the Immediate Care/Pre and Post operation nursing department of the hospital.

Medical gas alarm warning systems provide a means to continuously monitor the medical gas source equipment and the operating pressures in the pipeline distribution system, as well as, the critical care areas of the facility to ensure that the medical gas and vacuum systems remain safe for patient use.

Findings include:

- Review of the LSC complaint investigation results on 7/27/17 revealed the LSC Inspector discovered on 6/23/2017 10:59 am and 6/26/2017 at 9:30 am that the medical gas alarm panel that monitors the oxygen, medical air and vacuum pressures for the Immediate Care/Pre and Post operation nursing area did not work. (Refer to A-0709 for further details)

This deficient practice resulted in the LSC inspector of the state fire marshal's office notifying the hospital's administration that the Centers for Medicare and Medicaid Services (CMS) identified this as an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient/resident) on 6/26/2017 at 12:16 pm. The hospital removed the immediate jeopardy on 6/26/2017 at 2:49 pm by moving all patients out of the Immediate Care department and by replacing the power supply box and running a test to ensure the alarm panel was working properly.

Based on document review and Life Safety Code complaint investigation findings (KS00117589; ASPEN #OP2E21), the Hospital failed to meet the applicable provisions of the current Life Safety Code (LSC) as required by the NFPA (National Fire Protection Agency) when they failed to maintain the medical gas warning alarm system for the Immediate Care/Pre and Post Operation nursing department of the hospital.

Medical gas alarm warning systems provide a means to continuously monitor the medical gas source equipment and the operating pressures in the pipeline distribution system, as well as, the critical care areas of the facility to ensure that the medical gas and vacuum systems remain safe for patient use.

The hospital's failure to maintain the medical gas warning alarm system in the Immediate Care unit placed all patients receiving care in that nursing unit in danger of injury, harm, or death because of the potential for undetected changes in the pressure of the oxygen, medical gases, and the vacuum system.


Findings include:

- The facility had 54 certified beds at the time of survey and a census of 42.

- The LSC inspector's complaint inspection completed on June 30, 2017 revealed the following findings regarding the medical gas warning alarm system in the Immediate/Pre and Post Operation nursing unit:


1. On 6/23/2017 at 10:59 am, the LSC inspector noticed the medical gas alarm panel had no display on the panel. The Maintenance supervisor indicated he was not aware the panel was not working.

2. On 6/26/2017 at 9:30 am, the LSC inspector again noticed no display on the medical gas alarm panel. At that time, the Chief Operating Officer and the Risk Manager revealed 12 surgeries had been scheduled and performed.

3. On 6/26/2017 at 9:35 am, Unit nurse A and B stated they had not noticed the panel was not working. The Maintenance supervisor indicated he was going to try to find the part that he believed was the problem-the panel power supply.

4. On 6/26/2017, between 10:15 am and Noon, the hospital's nursing staff moved all the patients out of the Immediate care unit to the Intensive Care Unit.

5. On 6/26/2017 at 12:16 pm, the LSC inspector of the state fire marshal's office notified the hospital's administration that the Centers for Medicare and Medicaid Services (CMS) identified this as an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient/resident).

6. On 6/26/2017 at 2:35 pm, the Maintenance supervisor removed the old power supply box and replaced it with the delivered power supply. The supervisor re-energized the medical gas alarm panel at 2:49 pm and the digital psi (pounds per square inch-an indicator of pressure) readout and the green high/low pressure indicators began working.
The maintenance supervisor tested the panel and it worked. The hospital removed the immediate jeopardy at that time.

7. On 6/26/2017 at 3:15 pm, the Chief Operating Officer stated that he had not been advised that the panel was not working until he received the phone call from the LSC inspector at 8:30 am this morning. The LSC inspector indicated he notified the Maintenance Supervisor on June 23, 2017 (3 days prior) that the medical gas alarm panel was not functioning.

8. On 6/22,/2017, the Maintenance supervisor acknowledged during documentation review with the LSC inspector that the hospital did not have a medical gas maintenance, inspection, or testing program in place.


Refer to the attached Life Safety Code complaint survey results dated 6/30/17 (ASPEN # OP2E21) for additional details and NFPA references.