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Based on document review, and life safety code (LSC) complaint survey (ASPEN #FWE621; KS00173049) conducted by the Office of the Kansas State Fire Marshal (OSFM) on 07/08/22, the facility failed to inspect snd maintain their medical air gas system in compliance with National Fire Protection Association (NFPA) 99.

This deficient practice affects the emergency room and approximately 3 patients per day. The facility has a capacity of 25 with a census of 15 at the time of this survey.

Findings Include:

Review of a document titled, "Airgas Report," dated January 25, 2022 and received by the facility on February 7, 2022 showed the following:

1. Lag alarm is not installed, present and functioning at local alarm panel.
2. Local alarm is not tied into master alarm panel indicating a malfunction.
3. Automatic alternation is not operating correctly.
4. Vacuum gauge is not present at receiver.
5. Receiver cannot be isolated from system.
6. Receiver does not have a manual drain.
7. Vacuum exhaust is not located 10 feet from any door, window, air intake, other building opening or places of public assembly.
8. Vacuum exhaust discharge is not turned down.
9. Vacuum exhaust discharge is not screened.
10. Vacuum alarm visual alarm failure.
11. COMMENTS: Vacuum sensor needs to be replaced. Not reading accurately.

The hospital could not provide any evidence or documentation that any of the repairs or replacements of these deficiencies had been completed between February 7, 2022 and July 8, 2022.

On 07/08/22 at 3:42 PM, the facility was alerted that the issue is an IJ.

The Hospital was notified that they had successfully removed the Immediate Jeopardy at 3:55 PM on 07/08/22 by implementing the following actions: The facility is implementing portable suction and bottled oxygen in the emergency room until the medgas system repairs are completed.

The Chief Financial Officer and the Maintenance Director were present and acknowledged the findings.

Refer to W0930

See LSC complaint survey findings (KS00173049; ASPEN #FWE621 - K902 and K908) for further details.

Based on observation, staff interview, record review and life safety code (LSC) complaint survey findings(KS00173049; ASPEN #FWE621) the facility failed to inspect and maintain their medical air gas system in compliance with National Fire Protection Association (NFPA) 99.

This deficient practice could prevent the medical air gas system from working properly in the event of an emergency. This deficient practice affects the emergency room and approximately 3 patients per day. The facility has a capacity of 25 with a census of 15 at the time of this survey.

Findings Include:

Review of a document titled, "Airgas Report," dated January 25, 2022 and received by the facility on February 7, 2022 showed the following:

1. Lag alarm is not installed, present and functioning at local alarm panel.
2. Local alarm is not tied into master alarm panel indicating a malfunction.
3. Automatic alternation is not operating correctly.
4. Vacuum gauge is not present at receiver.
5. Receiver cannot be isolated from system.
6. Receiver does not have a manual drain.
7. Vacuum exhaust is not located 10 feet from any door, window, air intake, other building opening or places of public assembly.
8. Vacuum exhaust discharge is not turned down.
9. Vacuum exhaust discharge is not screened.
10. Vacuum alarm visual alarm failure.
11. COMMENTS: Vacuum sensor needs to be replaced. Not reading accurately.

The hospital could not provide any evidence or documentation that any of the repairs or replacements of these deficiencies had been completed between February 7, 2022 and July 8, 2022.

The Chief Financial Officer and the Maintenance Director were present and acknowledged the findings.


NFPA 99. 5.1.9.2* Master Alarms. A master alarm system shall be provided to monitor the operation and condition of the source of supply, the reserve source (if any), and the pressure in the main lines of each medical gas and vacuum piping system.
5.1.9.2.1 The master alarm system shall consist of two or more alarm panels located in at least two separate locations, as follows:
(1) One master alarm panel shall be located in the office or work space of the on-site individual responsible for the maintenance of the medical gas and vacuum piping systems.
(2) In order to ensure continuous surveillance of the medical gas and vacuum systems while the facility is in operation, the second master alarm panel shall be located in an area of continuous observation (e.g., the telephone switchboard, security office, or other continuously staffed location).

Review of the following NFPA Standard revealed: Medical air quality shall be monitored downstream of the medical air regulators and upstream of the piping system as follows:
(1) Dew point shall be monitored and shall activate a local alarm and all master alarms when the dew point at system delivery pressure exceeds +2°C (+35°F).
(2) Carbon monoxide shall be monitored and shall activate a local alarm when the CO level exceeds 10 ppm. [See 5.1.9.5.4(2).]
(3) Dew point and carbon monoxide monitors shall activate their individual monitor's signal at the alarm panels where their signals are required when their power is lost.

See LSC complaint survey findings (KS00173049; ASPEN #FWE621 - K902 and K908) for further details.