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Based on observations made on July 6, 2011, the facility failed to maintain the two-hour fire resistance rating of a fire barrier.

The findings include:

In accordance with Section 19.1.2.3 of NFPA 101, Life Safety Code (LSC), 2000 Edition; buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than two hours as provided of additions in Section 19.1.1.4.

1. The north fire wall in the Computerized Tomography (CT) Scan room in the lower level of the hospital was reviewed at 11:00 a.m. on July 6, 2011. A contractor had installed new wiring for a call light located on the north wall of this room. The conduit for this wiring extended through the fire wall and was not sealed.

2. The fire wall in the lower level located between the door to Purchasing and the elevator was reviewed at 11:05 a.m. on July 6, 2011. There was a five foot length of wall not sealed near the elevator along the top of the wall and ceiling deck.

3. The fire wall in the lower level located between the Purchasing office and the basement exit was reviewed at 11:15 a.m. on July 6, 2011. There were four penetrations above the ceiling tile in the Purchasing office. Two penetrations for half-inch water lines, one penetration for a four-inch sewer line, and another puncture hole approximately four inches in diameter.

Based on observations made on July 6, 2011, the facility failed to ensure that vertical openings between floors were sealed and/or enclosed by fire resistive construction.

The findings include:

In accordance with Section 19.3.1.1 of NFPA 101, 2000 Edition, any vertical opening shall be enclosed or protected in accordance with 8.2.5 of the Life Safety Code. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition, pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

The interior exit stairway near the cafeteria was observed at 10:50 a.m. on July 6, 2011. The ceiling of the stairway was not fire rated for a one-hour enclosure. A four foot by four foot area of the ceiling at the bottom of the stairway was not rated as a one hour enclosure.

Based on observations made on July 6, 2011,the facility failed to keep the proper number of spare heads in the spare head cabinet.

Findings include:

In accordance with Section 5.2.1.3 of NFPA-25, (1998 edition); the supply of spare sprinklers shall be inspected annually for the following:

(a) The proper number and type of sprinklers
(b) A sprinkler wrench for each type of sprinkler.

The spare head cabinet was observed in the boiler room near the sprinkler control valves. The cabinet had one spare head for side wall sprinkler heads and two spare heads for ceiling pendant heads. The Code requires the facility to have at least six spare heads of each type sprinkler which the facility may have.

Based on observations made on July 5, 2011, the facility failed to assure that portable fire extinguishers were readily accessible at all times.

The finding include:

Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire per section 1-6.3 of NFPA 10, 1998 Edition.

The penthouse located above the hospital section was observed at 3:50 p.m. on July 5, 2011. There was no fire extinguisher available in the penthouse.

Based on observations made on July 5, 2011, the facility failed to provide documentation that numerous window curtains and valances were either fire resistant or had been treated with a product made for fabrics to render them fire retardant.

The findings include:

In accordance with 19.7.5.1 and 10.3.1 of NFPA 101; draperies, curtains or other loosely hanging fabrics in health care occupancies shall be flame resistant as demonstrated by testing in accordance with NFPA 701.

1. The Recovery room curtains were reviewed for documentation at 4:55 p.m. on July 5, 2011. There was not documentation that the curtains had been treated with a fire resistant material to render them fire retardant.

2. The wall hanging near room 102 in the Intensive Care Unit was observed for documentation at 5:05 p.m. on July 5, 2011. There was not documentation that the wall hanging had been treated with a fire resistant material to render them fire retardant.

Based on observation and record review on July 5, 2011, the facility failed to store empty oxygen cylinders separate from full cylinders in the Nitrous storeroom, the electrical switch placement was not at least five feet from the floor, the Nitrous storeroom lacked sufficient ventilation, and failed to properly secure all oxygen cylinders.

Findings include:

In accordance with Section 4-3.5.2.2 of NFPA 99 (1999 Edition); (Storage of Cylinders and Containers) for Level 1.
(a) * Facility authorities, in consultation with medical staff and other trained personnel, shall provide and enforce regulations for the storage and handling of cylinders and containers of oxygen and nitrous oxide in storage rooms of approved construction, and for the safe handling of these agents in anesthetizing locations. Storage locations for flammable inhalation anesthetic agents, established in any operating or delivery suite, shall be limited by space allocation and regulation to not more than a 48-hour normal requirement for any such suite. In storage locations, cylinders shall be properly secured in racks or adequately fastened. No cylinders containing oxygen or nitrous oxide, other than those connected to anesthetic apparatus, shall be kept or stored in anesthetizing locations.
(b) Nonflammable Gases.
1. Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier.
2. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

In accordance with 4-3.1.1.2 (11) (d) of NFPA 99 (1999 Edition); ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.

In accordance with Section 4-3.1.1.2 (b) (4) and (c) of NFPA 99 (1999 Edition); locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) shall be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 in.2 (0.05 m2) in total free area.
(c) Storage Requirements for Nonflammable Gases Less Than 3000 ft3 (85 m3). Doors to such locations shall be provided with louvered openings having a minimum of 72 square inches in total free area. Where the location of the supply system door opens onto an exit access corridor, louvered openings shall not be used, and the requirements of 4-3.1.1.2(b)3 and 4 and the dedicated mechanical ventilation system required in 4-3.1.1.2(b)4 shall be complied with.

1. The Nitrous storeroom was observed at 2:30 p.m. on July 5, 2011.

a) There were six empty oxygen cylinders being stored with full tanks on the south side of the storeroom.

Staff member A promptly moved the empty tanks to the stands on the north side of the room, where they were supposed to be stored.

b) The electrical system in the nitrous oxide storeroom was observed at 2:33 p.m. on July 5, 2011. The electrical switch plate was not located 60 inches above the floor as required.

c) The ventilation system was reviewed for the storeroom. There was no louvered or mechanical ventilation for the room. The ventilation did not meet the requirements of NFPA 4-3.1.1.2 (b) (4) or (c). The lacked at least 72 square inches of louvered opening for free ventilation.

In accordance with Sections 8-3.1.22.2(h) and 4-3.5.2.1(b 27) of NFPA 99 (1999 Edition); freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

2. The Ambulance office was observed at 3:15 p.m. on July 5, 2011. One "D" size oxygen tank was not properly secured.

Based on observation and record review on July 5, 2011, the facility failed to provide both the Oxygen and Nitrous Oxide systems with duplex final line pressure regulators, the Nitrous Oxide manifold is defective and has been modified so as not to be capable of operation as manufactured, no master alarm panel or indicators were installed to monitor the systems, no emergency oxygen supply connection was provided for the cryogenic oxygen supply, and the Annual Medical Gas report identified several immediate concerns with the Med Gas and Vacuum systems which were not properly addressed on a timely basis possibly exposing patients/residents to hazardous conditions.

Findings include:

In accordance with Section 4-3.1.1.8 (1) (g) of NFPA 99 (1999 Edition); final line regulators shall be duplexed with suitable valving to permit service to the regulators without completely shutting down the gas piping system.

1. The bulk oxygen and nitrous oxide systems were observed and reviewed at 2:30 p.m. on July 5, 2011.

a) Both the Oxygen and Nitrous Oxide systems have only one final line regulator. By Code, they are to be duplexed with suitable valving to permit service on the regulators without completely shutting down the gas piping system.

In accordance with Section 4-3.1.1.6 (a) - (f) of NFPA 99 (1999 Edition), Cylinder Supply Systems with Reserve Supply;

(a) A cylinder supply system with reserve supply shall consist of:
1. A primary supply, which supplies the piping system.
2. A secondary supply, which shall operate automatically when the primary supply is unable to supply the system. An actuating switch shall be connected to the master signal panels to indicate when, or just before, the changeover to the secondary bank occurs.
3. A reserve supply, which shall operate automatically in the event that both the primary and secondary supplies are unable to supply the system. An actuating switch shall be connected to the master signal panels to indicate when, or just before, the reserve begins to supply the piping system.
(b) * The reserve supply shall consist of three or more manifolded high-pressure cylinders connected as required under 4-3.1.1.8(b), and either shall be equipped with check valves as required in 4-3.1.1.5(b) or shall be provided with an actuating switch that shall operate the master signals when the reserve supply drops to one day ' s supply.
(c) * A cryogenic liquid storage vessel shall be installed either as indicated in Figure 4-3.1.1.6, or as indicated in Figure 4-3.1.1.5 with the addition of a reserve supply connected as shown in Figure 4-3.1.1.6.
(d) When cryogenic liquid storage vessels are designed to prevent the loss of the gas produced by the evaporation of the cryogenic liquid in the secondary supply, they shall be designed so that the gas produced shall pass through the line pressure regulator before entering the piped distribution system.
(e) Cryogenic liquid storage vessels shall be constructed to withstand high pressure [2200 psig (15.2 MPa gauge)] or shall be provided with suitable pressure relief devices upstream of the control unit.
(f) Cylinder supply systems designed in accordance with 4-3.1.1.6 do not require check valves between each cylinder lead and the manifold header on the primary and secondary supplies.
Figure 4-3.1.1.6 Typical cylinder supply system with reserve supply (schematic). Supply systems with different arrangements of valves and regulators are permissible if they provide equivalent safeguards. (Level 1 Gas Systems)

Further, In accordance with Section 4-3.1.1.7 (a) and (b), Bulk Medical Gas Systems, of NFPA 99 (1999 Edition);

(a) The bulk system shall consist of two sources of supply, one of which shall be a reserve supply for use only in an emergency. An actuating switch shall be connected to the master signal panels to indicate when, or just before, the reserve begins to supply the system. There are two types of bulk supply systems:
1. The alternating type with two or more units alternately supplying the piping system. When the primary supply is unable to supply the bulk system, the secondary supply automatically becomes the primary supply and a new secondary supply, not the reserve supply, is connected when or before this changeover takes place. An actuating switch shall be connected to the master signal panels to indicate when, or just before, the changeover occurs.
2. The continuous type with one or more units continuously supplying the piping system while another unit remains as the reserve supply and operates only in case of an emergency.
(b) The secondary supply and the reserve supply referred to in 4-3.1.1.7(a) shall each contain at least an average day ' s supply and shall consist of the following:
1. Three or more manifolded high-pressure cylinders connected as required under 4-3.1.1.5(a) and 4-3.1.1.8(b), and provided with an actuating switch, which shall operate the master alarm signal when the reserve supply is reduced to one day ' s average supply; or
2. A cryogenic liquid storage unit used as the reserve for a bulk supply system provided with an actuating switch that shall operate the master alarm signal when the contents of the reserve are reduced to one day ' s average supply, and another actuating switch that shall operate the master alarm signal if the gas pressure available in the reserve unit is reduced below the pressure required to function properly. It shall also be designed to prevent the loss of gas produced by the evaporation of the cryogenic liquid in the reserve and so that the gas produced shall pass through a line pressure regulator before entering the piped distribution system.
Figure 4-3.1.1.7 Typical bulk supply system (schematic). Bulk supply systems with different arrangements of valves, regulators, and gas supply units are permissible if they provide equivalent safeguards. The reserve supply shown in dotted lines indicates the arrangements outlined in 4-3.1.1.7(b)2 or 3. (Level 1 Gas Systems)

In accordance with Section 4-3.1.1.8 (a) - (g) (General Requirements for Gas Central Supply Systems);
Piped oxygen and medical air shall not be piped to, or used for, any purpose except for use in patient care applications.
(a) Cylinders. Cylinders shall be designed, constructed, tested, and maintained in accordance with 4-3.1.1.1(a). Cylinders in service shall be adequately secured. Cylinders in storage shall be secured and located to prevent them from falling or being knocked over.
(b) Manifolds. Manifolds shall be of substantial construction and of a design and materials suitable for the gases and pressures involved. Mechanical means shall be provided to ensure the connection of cylinders containing the proper gas to the manifold. Cylinder valve outlets and manifold or regulator inlet connections shall comply with the CGA Pamphlet V-1, Standard for Compressed Gas Cylinder Valve Outlet and Inlet Connections (ANSI B57.1, CGA B96). When any nonflammable medical gases or gas mixtures are to be piped, care shall be taken to ensure noninterchangeability of cylinders or equipment. Manifolds shall be obtained from and installed under the supervision of a manufacturer or supplier familiar with proper practices for their construction and use.
(c) Pressure Regulation. Pressure-regulating equipment shall be installed in the supply main upstream of the final line-pressure relief valve [see 4-3.1.1.8(e)]. Where multiple piping systems for the same gas at different operating pressures are required, separate pressure-regulating equipment, relief valves, and source shutoff valves shall be provided for each pressure.
(d) Shutoff Valves. A manually operated shutoff valve shall be installed upstream of each pressure regulator, and a shutoff valve or a check valve shall be installed downstream.
(e) Pressure Relief Valves. Each central supply system shall have a pressure relief valve set at 50 percent above normal line pressure, installed downstream of the pressure regulator and upstream of any shutoff valve. This pressure relief valve shall be permitted to be set at a higher pressure, provided another pressure relief valve set at 50 percent above normal line pressure is installed in the main supply line. All pressure relief valves shall close automatically when excess pressure has been released. Pressure relief valves set at 50 percent above normal line pressure shall be vented to the outside from all gas systems, except medical air, or if the total capacity of the supply system is in excess of 3000 ft3 (85 m3) of gas. Pressure relief valves shall be of brass or bronze and specially designed for the gas service involved.
1. The pressure relief valve downstream of the line pressure regulator in nitrogen systems used to provide power for gas-driven medical tools or instruments, and for other systems that vary from the normal 50- to 55-psig (340- to 380-kPa gauge) line pressure (for example, systems supplying medical gases to hyperbaric chambers), shall be set at 50 percent above line pressure.
(f) Check Valves. Supply systems complying with 4-3.1.1.6 or 4-3.1.1.7 (see Figures 4-3.1.1.6 and 4-3.1.1.7) shall have a check valve in the primary supply main, upstream of the point of intersection with the secondary or reserve supply main.
(g) Final Line Regulators. Final line regulators shall be duplexed with suitable valving to permit service to the regulators without completely shutting down the gas piping system.

2. The Nitrous Oxide supply manifold was observed and reviewed at 2:35 p.m. on July 5, 2011.

a) The manifold has been modified so as not to be capable of operation as manufactured and may be defective.

This was also noted by the contractor in the annual report dated March 8, 2011. The report states that, "the manifold is defective and no longer operates as intended by the manufacturer and would be the responsibility of the hospital in case of failure."

b) The Annual Medical Gas report dated March 8, 2011 was reviewed for compliance. The report identified several immediate concerns, among them were:

1. No dual inlet pressure regulators
2. Manifold is not equipped with status warning lights
3. No dual outlet pressure regulators
4. High/Low pressure switch is located upstream from the source valve, and should be downstream
5. The high/low pressure switch is not connected using a gas specific demand check connector
6. There is no pressure gauge downstream of the source valve and visible from a standing position.

An interview with the Staff Member A during a phone conversation at 10:30 a.m. on July 13, 2011, revealed that no action had been taken on the concerns which were identified in the report. (See the Medical Gas Piping & Vacuum Systems Annual Prevention Maintenance Verification Report dated March 8, 2011 for further information.)

In accordance with Section 4-3.1.1.7 (a) of NFPA 99 (1999 Edition); the bulk system shall consist of two sources of supply, one of which shall be a reserve supply for use only in an emergency. An actuating switch shall be connected to the master signal panels to indicate when, or just before, the reserve begins to supply the system. There are two types of bulk supply systems:

1. The alternating type with two or more units alternately supplying the piping system. When the primary supply is unable to supply the bulk system, the secondary supply automatically becomes the primary supply and a new secondary supply, not the reserve supply, is connected when or before this changeover takes place. An actuating switch shall be connected to the master signal panels to indicate when, or just before, the changeover occurs.
2. The continuous type with one or more units continuously supplying the piping system while another unit remains as the reserve supply and operates only in case of an emergency.
(b) The secondary supply and the reserve supply referred to in 4-3.1.1.7(a) shall each contain at least an average day ' s supply and shall consist of the following:
1. Three or more manifolded high-pressure cylinders connected as required under 4-3.1.1.5(a) and 4-3.1.1.8(b), and provided with an actuating switch, which shall operate the master alarm signal when the reserve supply is reduced to one day ' s average supply; or
2. A cryogenic liquid storage unit used as the reserve for a bulk supply system provided with an actuating switch that shall operate the master alarm signal when the contents of the reserve are reduced to one day's average supply, and another actuating switch that shall operate the master alarm signal if the gas pressure available in the reserve unit is reduced below the pressure required to function properly. It shall also be designed to prevent the loss of gas produced by the evaporation of the cryogenic liquid in the reserve and so that the gas produced shall pass through a line pressure regulator before entering the piped distribution system.

3. The bulk oxygen supply system was observed and reviewed at 2:45 p.m. on July 5, 2011.

a) There are no master alarm indicators as there is no master alarm panel for the system.

In accordance with Section 4-3.1.1.8 (1) (h) of NFPA 99 (1999 Edition); where the cryogenic oxygen supply is located outside of the building served, there shall be incorporated in the piping system and inlet for connecting a temporary auxiliary source of supply for emergency or maintenance situations. The inlet shall be located on the exterior of the building served and shall be physically protected to prevent tampering and unauthorized access. It shall be labeled EMERGENCY LOW PRESSURE GASEOUS OXYGEN INLET. This connection shall be installed downstream of the shutoff valve on the main supply line [see 4-3.1.2.3(b)] and be suitably controlled with the necessary valves to allow emergency supply of oxygen and isolation of the piping to the normal source of supply. It shall have one check valve in the main line between the main line shutoff valve and the tee'd connection and one check valve between the tee'd connection and the emergency supply shutoff valve.

4. The emergency oxygen supply connection for the cryogenic oxygen supply was observed and reviewed at 2:48 p.m. on July 5, 2011. The bulk medical gas system was observed to be of the continuous type with one or more units continuously supplying the piping system while another unit remains as the reserve supply and operates only in the case of an emergency.

a) There is no emergency oxygen supply connection at the cryogenic oxygen supply tank.


In accordance with Section 4-3.2.2.8 (a) (Master Alarm System for Vacuum Systems), of NFPA 99 (1999 Edition); to ensure continuous responsible observation, the master alarm signal panels shall be located in two separate warning locations, wired in parallel to a single sensor to indicate when the vacuum in the main line drops below the level required in 4-3.4.2.2(c)4b. Audible and noncancelable visual signals shall be installed in the office or principal working area of the individual responsible for the maintenance of the vacuum system and, to ensure continuous surveillance, at the telephone switchboard, the security office, or other continuously staffed locations.

In accordance with 4.3.3.2.2 (c) (4b) of NFPA 99 (1999 Edition); unless otherwise indicated, vacuum system alarms shall indicate if the vacuum in the piping system drops to 12 in. Hg and below.

5. Review of the Inspection Report for the Vacuum System indicated that there was no "lag alarm installed to indicate if the vacuum in the piping system drops to 12 inches Hg and below." Section 4-3.2.2.8 (a) of NFPA 99 (1999 Edition) requires that audible and noncancelable visual signals shall be installed in the office or principal working area of the individual responsible for the maintenance of the vacuum system and to ensure continuous surveillance, at the telephone switchboard, the security office, or other continuously staffed locations.

In accordance with Section 4-3.4.1.3 (c) (2) of NFPA 99 (1999 Edition); oxygen, nitrous oxide, and air outlets shall deliver 3.5 SCFM with a pressure drop of no more than 5 psig (35 kPa), and static pressure of 50 psig (349 kPa).

6. Review of the Inspection Report for the Outlets Tested for the Vacuum, Oxygen and Nitrous Oxide piping indicated that there were problems at the following locations:

Vacuum
a) Emergency Room Treatment room outlet line was broken.
b) Recovery Room outlet line was broken.
c) Sleep Study Room 1, vacuum outlets 1 and 2 broken.

Oxygen
a) Intensive Care Unit Room 101 at outlet 3 had a leaky connector.
b) Labor & Delivery at the Nursery at outlet 3 had a leaky connector.
c) Respiratory Therapy, Room 1, outlet 2 was broken and outlet 3 had a leaking connector.
d) Surgery A at outlet 6, had a greater than 5 PSIG drop in flow rate.
e) Surgery B at outlet 4, had a greater than 5 PSIG drop in the flow rate.

Nitrous Oxide
a) Surgery A at outlet 5 had a greater than 5 PSIG drop in the flow rate.
b) Surgery B at outlet 3 had a greater than 5 PSIG drop in the flow rate.

Based on observation and record reviewon July 5, 2011, all of the anesthetizing locations were not protected in accordance with NFPA 99, Standard for Health Care Facilities.

In accordance with Section 4-3.1.2.3 (n) of NFPA 99 (1999 Edition); a shutoff valve shall be located outside each anesthetizing location in each medical gas line, so located as to be readily accessible at all times for use in an emergency. These valves shall be so arranged that shutting off the supply of gas to any one operating room or anesthetizing location will not affect the others. Valves shall be of an approved type, mounted on a pedestal or otherwise properly safeguarded against physical damage, and marked in accordance with 4-3.5.4.2.

Finding include:

The Emergency Treatment room and Respiratory Therapy areas were observed and reviewed at 5:05 p.m. on July 5, 2011. The Emergency Treatment room is a critical care area, the Respiratory Therapy (RT) area is considered a noncritical care area, these two areas are on the same zone valve. The zone valve was labeled Emergency Room (ER), but also controlled the oxygen which was being used for RT. These two different care areas can not be on the same zone valve. (See K 140 for additional information)

Based on observations and record review made on July 5 and 6, 2011, the facility failed to assure that:
- all critical care areas of the hospital had area alarms for the medical gas system,
- zone valves have a pressure gauge downstream to indicate pressure in the line,
- proper labeling was provided for all gas valves,
- zone valves were not located behind normally open or closed doors, and
- there were no master alarm panels to supervise potential system failures.

The examples in this case were:

In accordance with 4-3.1.2.2 (c) (1) of NFPA 99 (1999 Edition); area alarms shall be provided for each medical gas piping system supplying anesthetizing locations and other vital life support and critical care areas such as post anaesthesia recovery, intensive care units, and coronary care units.

In accordance with 4-3.1.2.2 (b) (1) - (3) of NFPA 99 (1999 Edition);
1. A master alarm system shall be provided to monitor the operation and condition of the source of supply, the reserve (if any), and the pressure of the main lines of all medical gas piping systems.
2. The master alarm system shall consist of two or more alarm panels located in two separate locations. One panel shall be located in the principal working area of the individual responsible for the maintenance of the medical gas piping systems and one or more panels shall be located to assure continuous surveillance during the working hours of the facility (e.g., the telephone switchboard, security office, or other continuously staffed location).
3. Each master alarm panel shall include visual indicators for each of the following conditions:
a. * A separate indicator shall be provided for all systems supplied by a manifold or an alternating-type bulk system that has as part of its normal operation a changeover from one portion of the operating supply to another portion. It shall indicate when, or just before, this changeover occurs.
b. * Where a manifold or bulk supply consists of one or more units that continuously supply the piping system while another unit remains as the reserve supply and operates only in case of an emergency, it shall be indicated separately for each system when, or just before, this changeover occurs.
c. * Where check valves are not provided for each cylinder lead of the reserve supply for a manifold or bulk supply system, it shall be indicated separately for each system when the reserve supply is reduced to one average day ' s supply. If check valves are provided in each cylinder lead, this signal is not required.
d. When a cryogenic liquid storage unit is used as a reserve for a bulk supply system, it shall be indicated separately for each system when the contents of the reserve is reduced to one average day ' s supply and when the gas pressure available in the reserve unit is reduced below the pressure required to function properly.
e. * It shall be indicated separately for each medical gas piping system when the pressure in the main line increases 20 percent or decreases 20 percent from the normal operating pressure. The actuating switch for these signals shall be installed in the main line immediately downstream (on the piping distributing side) of the main line shutoff valve or the source valve if the main line shutoff valve is not required.
f. Each of the individual alarms required in 4-3.1.2.2(d)1 shall be indicated. This shall be either by a separate indicator for each condition monitored or with a single indicator labeled " Medical Air System Fault " or similar wording and that indicates when any of the conditions monitored occurs.
g. A separate indicator shall be provided for dew point per 4-3.1.2.2(d)2.

In accordance with 4-3.1.2.3 (c) (2) of NFPA 99 (1999 Edition); area alarm panels shall be located at the nurses' station or other location that will provide for responsible surveillance.

In accordance with Section 4-3.1.2.3 (c) (3) of NFPA 99 (1999 Edition); area alarms shall indicate if the pressure in the local line increases 20 percent or decreases 20 percent from normal line pressure.

In accordance with Section 4-3.1.2.3 (e) (2) of NFPA 99 (1999 Edition); an appropriately identified pressure gauge, connected to the line being monitored, shall be installed at each area alarm panel location. It shall be appropriately labeled and shall be readily visible from a standing position.

In accordance with Section 4-3.1.2.3 (i) of NFPA 99 (1999 Edition); manual shutoff valves in boxes shall be installed where they are visible and accessible at all times. The boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.

In accordance with Section 4-3.1.2.3 (n) of NFPA 99 (1999 Edition); a shutoff valve shall be located outside each anesthetizing location in each medical gas line, so located as to be readily accessible at all times for use in an emergency. These valves shall be so arranged that shutting off the supply of gas to any one operating room or anesthetizing location will not affect the others. Valves shall be of an approved type, mounted on a pedestal or otherwise properly safeguarded against physical damage, and marked in accordance with 4-3.5.4.2.

1. The zone valve across from the Recovery room was examined at 4:50 p.m. on July 5, 2011.

a) The Critical Care Area does not have an Area Alarm, and
b) There were no Gauges on the Valve to monitor the pressures.

2. The zone valve inside the Endoscopy Cleaning room was examined at 4:57 p.m. on July 5, 2011. This valve serves the Endoscopy and Sleep Study areas.

a) The zone valves are inside a room and behind a normally open or closed door, and
b) There were no Gauges on the Valve to monitor the pressures

3. The zone valve to the left of the Emergency Room (ER) Treatment Room which serves ER-1 was examined at 5:00 p.m. on July 5, 2011. The Critical Care Area does not have an Area Alarm

4. The zone valve to the left of Respiratory Therapy which serves Respiratory Therapy and ER Treatment was examined at 5:05 p.m. on July 5, 2011.

a) The Critical Care Area does not have an Area Alarm, and
b) The Valve is incorrectly labeled for the gases, and
c) the Valve is not labeled for the Area Served as the valve controls a Critical Care Area and a Non Critical Care Area, i.e.: ER Treatment and Respiratory Therapy.

5. The zone valve to the left of the DEXA room near X-Ray was observed at 5:08 p.m. on July 5, 2011.

a) The zone valve was not labeled for the gases is served, and
b) There was no Gauge on the Valve to monitor pressures.

6. The zone valve by the Doctors entrance to Surgery which serves Surgery Room A was observed at 5:10 p.m. on July 5, 2011.

a) The Critical Care Area does not have an Area Alarm, and
b) There were no Gauges on the Valve to monitor pressures.

7. The zone valve to the right of the entrance to Surgery Room B was observed at 5:12 p.m. on July 5, 2011.

a) The Critical Care Area does not have an Area Alarm, and
b) There were no Gauges on the Valve to monitor pressures.

8. The zone valve to the left of room 101 which served Intensive Care Rooms 101 and 102 was observed at 5:20 p.m. on July 5, 2011. The Critical Care Area does not have an Area Alarm.

9. The Medical Gas Piping and Vacuum System Annual Preventive Maintenance Verification Report which was dated March 8, 2011, was reviewed for compliance. The report identified several immediate concerns which may pose hazards to patients/residents. The report identified that there were no Master Alarm Panels monitoring the condition of the source supplies in order to warn personnel of a potential failure until the pressure levels of the source have reached a point they may no longer be adequate for patient use.

Based on observations made on July 5 and 6, 2011, the facility failed to maintain the electrical system in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition and interpretations from the Centers for Medicare and Medicaid Services (CMS).

The findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 (b)(3) of NFPA 70. In accordance with UL listing for power strips (relocatable power taps as identified under UL standard 1363 and listings starting with XBYS) there must be a reset or test button identified for the circuit breaker to be reset.

1. The Accounting office was observed at 2:00 p.m. on July 5, 2011. A white extension cord was found under a desk in use.

2. The Medical Records storage area had a surge cord plugged into another surge cord as observed at 2:10 p.m. on July 5, 2011.

3. The Housekeeping Supervisors office had an orange extension cord in use to a camera located above the ceiling tile as observed at 2:15 p.m. on July 5, 2011.

In accordance with Article 110-13(a) of NFPA 70, electrical equipment shall be firmly secured to the surface on which it is mounted.

4. The Business office had two separate surge cords which did not rest entirely on the floor but were dangling in air and not supported properly as observed at 4:40 p.m. on July 5, 2011.

5. The Sleep Study office had a surge cord which was not supported properly, but was dangling in air as observed at 4:45 p.m. on July 5, 2011.

Based on observations made on July 5, 2011, the facility failed to prevent the installation of an Alcohol Based Hand Rub (ABHR) dispenser directly over an ignition source.

The findings include:

In accordance with CMS interpretations (Ref: S&C-05-33) issued on June 9, 2005 ABHR dispensers shall meet the NFPA amendment to the 2000 Life Safety Code regarding the installation of ABHR dispensers in exit corridors and on interior walls. The Sate Survey Agency (SA) enforces that ABHR dispensers be offset by at least one inch and not mounted directly above any electrical source.

The ABHR dispenser located in the Pharmacy office was located directly over a light switch as observed at 4:00 p.m. on July 5, 2011.

Based on observations made on July 6, 2011, the facility failed to maintain the two-hour fire resistance rating of a fire barrier.

The findings include:

In accordance with Section 19.1.2.3 of NFPA 101, Life Safety Code (LSC), 2000 Edition; buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than two hours as provided of additions in Section 19.1.1.4.

1. The north fire wall in the Computerized Tomography (CT) Scan room in the lower level of the hospital was reviewed at 11:00 a.m. on July 6, 2011. A contractor had installed new wiring for a call light located on the north wall of this room. The conduit for this wiring extended through the fire wall and was not sealed.

2. The fire wall in the lower level located between the door to Purchasing and the elevator was reviewed at 11:05 a.m. on July 6, 2011. There was a five foot length of wall not sealed near the elevator along the top of the wall and ceiling deck.

3. The fire wall in the lower level located between the Purchasing office and the basement exit was reviewed at 11:15 a.m. on July 6, 2011. There were four penetrations above the ceiling tile in the Purchasing office. Two penetrations for half-inch water lines, one penetration for a four-inch sewer line, and another puncture hole approximately four inches in diameter.

Based on observations made on July 6, 2011, the facility failed to ensure that vertical openings between floors were sealed and/or enclosed by fire resistive construction.

The findings include:

In accordance with Section 19.3.1.1 of NFPA 101, 2000 Edition, any vertical opening shall be enclosed or protected in accordance with 8.2.5 of the Life Safety Code. Where enclosure is provided, the construction shall have not less than a 1-hour resistance rating.

In accordance with Section 8.3.6.1 of NFPA 101, 2000 Edition, pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected/filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.

The interior exit stairway near the cafeteria was observed at 10:50 a.m. on July 6, 2011. The ceiling of the stairway was not fire rated for a one-hour enclosure. A four foot by four foot area of the ceiling at the bottom of the stairway was not rated as a one hour enclosure.

Based on observations made on July 6, 2011,the facility failed to keep the proper number of spare heads in the spare head cabinet.

Findings include:

In accordance with Section 5.2.1.3 of NFPA-25, (1998 edition); the supply of spare sprinklers shall be inspected annually for the following:

(a) The proper number and type of sprinklers
(b) A sprinkler wrench for each type of sprinkler.

The spare head cabinet was observed in the boiler room near the sprinkler control valves. The cabinet had one spare head for side wall sprinkler heads and two spare heads for ceiling pendant heads. The Code requires the facility to have at least six spare heads of each type sprinkler which the facility may have.

Based on observations made on July 5, 2011, the facility failed to assure that portable fire extinguishers were readily accessible at all times.

The finding include:

Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire per section 1-6.3 of NFPA 10, 1998 Edition.

The penthouse located above the hospital section was observed at 3:50 p.m. on July 5, 2011. There was no fire extinguisher available in the penthouse.

Based on observations made on July 5, 2011, the facility failed to provide documentation that numerous window curtains and valances were either fire resistant or had been treated with a product made for fabrics to render them fire retardant.

The findings include:

In accordance with 19.7.5.1 and 10.3.1 of NFPA 101; draperies, curtains or other loosely hanging fabrics in health care occupancies shall be flame resistant as demonstrated by testing in accordance with NFPA 701.

1. The Recovery room curtains were reviewed for documentation at 4:55 p.m. on July 5, 2011. There was not documentation that the curtains had been treated with a fire resistant material to render them fire retardant.

2. The wall hanging near room 102 in the Intensive Care Unit was observed for documentation at 5:05 p.m. on July 5, 2011. There was not documentation that the wall hanging had been treated with a fire resistant material to render them fire retardant.

Based on observation and record review on July 5, 2011, the facility failed to store empty oxygen cylinders separate from full cylinders in the Nitrous storeroom, the electrical switch placement was not at least five feet from the floor, the Nitrous storeroom lacked sufficient ventilation, and failed to properly secure all oxygen cylinders.

Findings include:

In accordance with Section 4-3.5.2.2 of NFPA 99 (1999 Edition); (Storage of Cylinders and Containers) for Level 1.
(a) * Facility authorities, in consultation with medical staff and other trained personnel, shall provide and enforce regulations for the storage and handling of cylinders and containers of oxygen and nitrous oxide in storage rooms of approved construction, and for the safe handling of these agents in anesthetizing locations. Storage locations for flammable inhalation anesthetic agents, established in any operating or delivery suite, shall be limited by space allocation and regulation to not more than a 48-hour normal requirement for any such suite. In storage locations, cylinders shall be properly secured in racks or adequately fastened. No cylinders containing oxygen or nitrous oxide, other than those connected to anesthetic apparatus, shall be kept or stored in anesthetizing locations.
(b) Nonflammable Gases.
1. Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier.
2. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

In accordance with 4-3.1.1.2 (11) (d) of NFPA 99 (1999 Edition); ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.

In accordance with Section 4-3.1.1.2 (b) (4) and (c) of NFPA 99 (1999 Edition); locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) shall be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 in.2 (0.05 m2) in total free area.
(c) Storage Requirements for Nonflammable Gases Less Than 3000 ft3 (85 m3). Doors to such locations shall be provided with louvered openings having a minimum of 72 square inches in total free area. Where the location of the supply system door opens onto an exit access corridor, louvered openings shall not be used, and the requirements of 4-3.1.1.2(b)3 and 4 and the dedicated mechanical ventilation system required in 4-3.1.1.2(b)4 shall be complied with.

1. The Nitrous storeroom was observed at 2:30 p.m. on July 5, 2011.

a) There were six empty oxygen cylinders being stored with full tanks on the south side of the storeroom.

Staff member A promptly moved the empty tanks to the stands on the north side of the room, where they were supposed to be stored.

b) The electrical system in the nitrous oxide storeroom was observed at 2:33 p.m. on July 5, 2011. The electrical switch plate was not located 60 inches above the floor as required.

c) The ventilation system was reviewed for the storeroom. There was no louvered or mechanical ventilation for the room. The ventilation did not meet the requirements of NFPA 4-3.1.1.2 (b) (4) or (c). The lacked at least 72 square inches of louvered opening for free ventilation.

In accordance with Sections 8-3.1.22.2(h) and 4-3.5.2.1(b 27) of NFPA 99 (1999 Edition); freestanding cylinders of nonflammable gases (such as oxygen) shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down.

2. The Ambulance office was observed at 3:15 p.m. on July 5, 2011. One "D" size oxygen tank was not properly secured.

Based on observation and record review on July 5, 2011, the facility failed to provide both the Oxygen and Nitrous Oxide systems with duplex final line pressure regulators, the Nitrous Oxide manifold is defective and has been modified so as not to be capable of operation as manufactured, no master alarm panel or indicators were installed to monitor the systems, no emergency oxygen supply connection was provided for the cryogenic oxygen supply, and the Annual Medical Gas report identified several immediate concerns with the Med Gas and Vacuum systems which were not properly addressed on a timely basis possibly exposing patients/residents to hazardous conditions.

Findings include:

In accordance with Section 4-3.1.1.8 (1) (g) of NFPA 99 (1999 Edition); final line regulators shall be duplexed with suitable valving to permit service to the regulators without completely shutting down the gas piping system.

1. The bulk oxygen and nitrous oxide systems were observed and reviewed at 2:30 p.m. on July 5, 2011.

a) Both the Oxygen and Nitrous Oxide systems have only one final line regulator. By Code, they are to be duplexed with suitable valving to permit service on the regulators without completely shutting down the gas piping system.

In accordance with Section 4-3.1.1.6 (a) - (f) of NFPA 99 (1999 Edition), Cylinder Supply Systems with Reserve Supply;

(a) A cylinder supply system with reserve supply shall consist of:
1. A primary supply, which supplies the piping system.
2. A secondary supply, which shall operate automatically when the primary supply is unable to supply the system. An actuating switch shall be connected to the master signal panels to indicate when, or just before, the changeover to the secondary bank occurs.
3. A reserve supply, which shall operate automatically in the event that both the primary and secondary supplies are unable to supply the system. An actuating switch shall be connected to the master signal panels to indicate when, or just before, the reserve begins to supply the piping system.
(b) * The reserve supply shall consist of three or more manifolded high-pressure cylinders connected as required under 4-3.1.1.8(b), and either shall be equipped with check valves as required in 4-3.1.1.5(b) or shall be provided with an actuating switch that shall operate the master signals when the reserve supply drops to one day ' s supply.
(c) * A cryogenic liquid storage vessel shall be installed either as indicated in Figure 4-3.1.1.6, or as indicated in Figure 4-3.1.1.5 with the addition of a reserve supply connected as shown in Figure 4-3.1.1.6.
(d) When cryogenic liquid storage vessels are designed to prevent the loss of the gas produced by the evaporation of the cryogenic liquid in the secondary supply, they shall be designed so that the gas produced shall pass through the line pressure regulator before entering the piped distribution system.
(e) Cryogenic liquid storage vessels shall be constructed to withstand high pressure [2200 psig (15.2 MPa gauge)] or shall be provided with suitable pressure relief devices upstream of the control unit.
(f) Cylinder supply systems designed in accordance with 4-3.1.1.6 do not require check valves between each cylinder lead and the manifold header on the primary and secondary supplies.
Figure 4-3.1.1.6 Typical cylinder supply system with reserve supply (schematic). Supply systems with different arrangements of valves and regulators are permissible if they provide equivalent safeguards. (Level 1 Gas Systems)

Further, In accordance with Section 4-3.1.1.7 (a) and (b), Bulk Medical Gas Systems, of NFPA 99 (1999 Edition);

(a) The bulk system shall consist of two sources of supply, one of which shall be a reserve supply for use only in an emergency. An actuating switch shall be connected to the master signal panels to indicate when, or just before, the reserve begins to supply the system. There are two types of bulk supply systems:
1. The alternating type with two or more units alternately supplying the piping system. When the primary supply is unable to supply the bulk system, the secondary supply automatically becomes the primary supply and a new secondary supply, not the reserve supply, is connected when or before this changeover takes place. An actuating switch shall be connected to the master signal panels to indicate when, or just before, the changeover occurs.
2. The continuous type with one or more units continuously supplying the piping system while another unit remains as the reserve supply and operates only in case of an emergency.
(b) The secondary supply and the reserve supply referred to in 4-3.1.1.7(a) shall each contain at least an average day ' s supply and shall consist of the following:
1. Three or more manifolded high-pressure cylinders connected as required under 4-3.1.1.5(a) and 4-3.1.1.8(b), and provided with an actuating switch, which shall operate the master alarm signal when the reserve supply is reduced to one day ' s average supply; or
2. A cryogenic liquid storage unit used as the reserve for a bulk supply system provided with an actuating switch that shall operate the master alarm signal when the contents of the reserve are reduced to one day ' s average supply, and another actuating switch that shall operate the master alarm signal if the gas pressure available in the reserve unit is reduced below the pressure required to function properly. It shall also be designed to prevent the loss of gas produced by the evaporation of the cryogenic liquid in the reserve and so that the gas produced shall pass through a line pressure regulator before entering the piped distribution system.
Figure 4-3.1.1.7 Typical bulk supply system (schematic). Bulk supply systems with different arrangements of valves, regulators, and gas supply units are permissible if they provide equivalent safeguards. The reserve supply shown in dotted lines indicates the arrangements outlined in 4-3.1.1.7(b)2 or 3. (Level 1 Gas Systems)

In accordance with Section 4-3.1.1.8 (a) - (g) (General Requirements for Gas Central Supply Systems);
Piped oxygen and medical air shall not be piped to, or used for, any purpose except for use in patient care applications.
(a) Cylinders. Cylinders shall be designed, constructed, tested, and maintained in accordance with 4-3.1.1.1(a). Cylinders in service shall be adequately secured. Cylinders in storage shall be secured and located to prevent them from falling or being knocked over.
(b) Manifolds. Manifolds shall be of substantial construction and of a design and materials suitable for the gases and pressures involved. Mechanical means shall be provided to ensure the connection of cylinders containing the proper gas to the manifold. Cylinder valve outlets and manifold or regulator inlet connections shall comply with the CGA Pamphlet V-1, Standard for Compressed Gas Cylinder Valve Outlet and Inlet Connections (ANSI B57.1, CGA B96). When any nonflammable medical gases or gas mixtures are to be piped, care shall be taken to ensure noninterchangeability of cylinders or equipment. Manifolds shall be obtained from and installed under the supervision of a manufacturer or supplier familiar with proper practices for their construction and use.
(c) Pressure Regulation. Pressure-regulating equipment shall be installed in the supply main upstream of the final line-pressure relief valve [see 4-3.1.1.8(e)]. Where multiple piping systems for the same gas at different operating pressures are required, separate pressure-regulating equipment, relief valves, and source shutoff valves shall be provided for each pressure.
(d) Shutoff Valves. A manually operated shutoff valve shall be installed upstream of each pressure regulator, and a shutoff valve or a check valve shall be installed downstream.
(e) Pressure Relief Valves. Each central supply system shall have a pressure relief valve set at 50 percent above normal line pressure, installed downstream of the pressure regulator and upstream of any shutoff valve. This pressure relief valve shall be permitted to be set at a higher pressure, provided another pressure relief valve set at 50 percent above normal line pressure is installed in the main supply line. All pressure relief valves shall close automatically when excess pressure has been released. Pressure relief valves set at 50 percent above normal line pressure shall be vented to the outside from all gas systems, except medical air, or if the total capacity of the supply system is in excess of 3000 ft3 (85 m3) of gas. Pressure relief valves shall be of brass or bronze and specially designed for the gas service involved.
1. The pressure relief valve downstream of the line pressure regulator in nitrogen systems used to provide power for gas-driven medical tools or instruments, and for other systems that vary from the normal 50- to 55-psig (340- to 380-kPa gauge) line pressure (for example, systems supplying medical gases to hyperbaric chambers), shall be set at 50 percent above line pressure.
(f) Check Valves. Supply systems complying with 4-3.1.1.6 or 4-3.1.1.7 (see Figures 4-3.1.1.6 and 4-3.1.1.7) shall have a check valve in the primary supply main, upstream of the point of intersection with the secondary or reserve supply main.
(g) Final Line Regulators. Final line regulators shall be duplexed with suitable valving to permit service to the regulators without completely shutting down the gas piping system.

2. The Nitrous Oxide supply manifold was observed and reviewed at 2:35 p.m. on July 5, 2011.

a) The manifold has been modified so as not to be capable of operation as manufactured and may be defective.

This was also noted by the contractor in the annual report dated March 8, 2011. The report states that, "the manifold is defective and no longer operates as intended by the manufacturer and would be the responsibility of the hospital in case of failure."

b) The Annual Medical Gas report dated March 8, 2011 was reviewed for compliance. The report identified several immediate concerns, among them were:

1. No dual inlet pressure regulators
2. Manifold is not equipped with status warning lights
3. No dual outlet pressure regulators
4. High/Low pressure switch is located upstream from the source valve, and should be downstream
5. The high/low pressure switch is not connected using a gas specific demand check connector
6. There is no pressure gauge downstream of the source valve and visible from a standing position.

An interview with the Staff Member A during a phone conversation at 10:30 a.m. on July 13, 2011, revealed that no action had been taken on the concerns which were identified in the report. (See the Medical Gas Piping & Vacuum Systems Annual Prevention Maintenance Verification Report dated March 8, 2011 for further information.)

In accordance with Section 4-3.1.1.7 (a) of NFPA 99 (1999 Edition); the bulk system shall consist of two sources of supply, one of which shall be a reserve supply for use only in an emergency. An actuating switch shall be connected to the master signal panels to indicate when, or just before, the reserve begins to supply the system. There are two types of bulk supply systems:

1. The alternating type with two or more units alternately supplying the piping system. When the primary supply is unable to supply the bulk system, the secondary supply automatically becomes the primary supply and a new secondary supply, not the reserve supply, is connected when or before this changeover takes place. An actuating switch shall be connected to the master signal panels to indicate when, or just before, the changeover occurs.
2. The continuous type with one or more units continuously supplying the piping system while another unit remains as the reserve supply and operates only in case of an emergency.
(b) The secondary supply and the reserve supply referred to in 4-3.1.1.7(a) shall each contain at least an average day ' s supply and shall consist of the following:
1. Three or more manifolded high-pressure cylinders connected as required under 4-3.1.1.5(a) and 4-3.1.1.8(b), and provided with an actuating switch, which shall operate the master alarm signal when the reserve supply is reduced to one day ' s average supply; or
2. A cryogenic liquid storage unit used as the reserve for a bulk supply system provided with an actuating switch that shall operate the master alarm signal when the contents of the reserve are reduced to one day's average supply, and another actuating switch that shall operate the master alarm signal if the gas pressure available in the reserve unit is reduced below the pressure required to function properly. It shall also be designed to prevent the loss of gas produced by the evaporation of the cryogenic liquid in the reserve and so that the gas produced shall pass through a line pressure regulator before entering the piped distribution system.

3. The bulk oxygen supply system was observed and reviewed at 2:45 p.m. on July 5, 2011.

a) There are no master alarm indicators as there is no master alarm panel for the system.

In accordance with Section 4-3.1.1.8 (1) (h) of NFPA 99 (1999 Edition); where the cryogenic oxygen supply is located outside of the building served, there shall be incorporated in the piping system and inlet for connecting a temporary auxiliary source of supply for emergency or maintenance situations. The inlet shall be located on the exterior of the building served and shall be physically protected to prevent tampering and unauthorized access. It shall be labeled EMERGENCY LOW PRESSURE GASEOUS OXYGEN INLET. This connection shall be installed downstream of the shutoff valve on the main supply line [see 4-3.1.2.3(b)] and be suitably controlled with the necessary valves to allow emergency supply of oxygen and isolation of the piping to the normal source of supply. It shall have one check valve in the main line between the main line shutoff valve and the tee'd connection and one check valve between the tee'd connection and the emergency supply shutoff valve.

4. The emergency oxygen supply connection for the cryogenic oxygen supply was observed and reviewed at 2:48 p.m. on July 5, 2011. The bulk medical gas system was observed to be of the continuous type with one or more units continuously supplying the piping system while another unit remains as the reserve supply and operates only in the case of an emergency.

a) There is no emergency oxygen supply connection at the cryogenic oxygen supply tank.


In accordance with Section 4-3.2.2.8 (a) (Master Alarm System for Vacuum Systems), of NFPA 99 (1999 Edition); to ensure continuous responsible observation, the master alarm signal panels shall be located in two separate warning locations, wired in parallel to a single sensor to indicate when the vacuum in the main line drops below the level required in 4-3.4.2.2(c)4b. Audible and noncancelable visual signals shall be installed in the office or principal working area of the individual responsible for the maintenance of the vacuum system and, to ensure continuous surveillance, at the telephone switchboard, the security office, or other continuously staffed locations.

In accordance with 4.3.3.2.2 (c) (4b) of NFPA 99 (1999 Edition); unless otherwise indicated, vacuum system alarms shall indicate if the vacuum in the piping system drops to 12 in. Hg and below.

5. Review of the Inspection Report for the Vacuum System indicated that there was no "lag alarm installed to indicate if the vacuum in the piping system drops to 12 inches Hg and below." Section 4-3.2.2.8 (a) of NFPA 99 (1999 Edition) requires that audible and noncancelable visual signals shall be installed in the office or principal working area of the individual responsible for the maintenance of the vacuum system and to ensure continuous surveillance, at the telephone switchboard, the security office, or other continuously staffed locations.

In accordance with Section 4-3.4.1.3 (c) (2) of NFPA 99 (1999 Edition); oxygen, nitrous oxide, and air outlets shall deliver 3.5 SCFM with a pressure drop of no more than 5 psig (35 kPa), and static pressure of 50 psig (349 kPa).

6. Review of the Inspection Report for the Outlets Tested for the Vacuum, Oxygen and Nitrous Oxide piping indicated that there were problems at the following locations:

Vacuum
a) Emergency Room Treatment room outlet line was broken.
b) Recovery Room outlet line was broken.
c) Sleep Study Room 1, vacuum outlets 1 and 2 broken.

Oxygen
a) Intensive Care Unit Room 101 at outlet 3 had a leaky connector.
b) Labor & Delivery at the Nursery at outlet 3 had a leaky connector.
c) Respiratory Therapy, Room 1, outlet 2 was broken and outlet 3 had a leaking connector.
d) Surgery A at outlet 6, had a greater than 5 PSIG drop in flow rate.
e) Surgery B at outlet 4, had a greater than 5 PSIG drop in the flow rate.

Nitrous Oxide
a) Surgery A at outlet 5 had a greater than 5 PSIG drop in the flow rate.
b) Surgery B at outlet 3 had a greater than 5 PSIG drop in the flow rate.

Based on observation and record reviewon July 5, 2011, all of the anesthetizing locations were not protected in accordance with NFPA 99, Standard for Health Care Facilities.

In accordance with Section 4-3.1.2.3 (n) of NFPA 99 (1999 Edition); a shutoff valve shall be located outside each anesthetizing location in each medical gas line, so located as to be readily accessible at all times for use in an emergency. These valves shall be so arranged that shutting off the supply of gas to any one operating room or anesthetizing location will not affect the others. Valves shall be of an approved type, mounted on a pedestal or otherwise properly safeguarded against physical damage, and marked in accordance with 4-3.5.4.2.

Finding include:

The Emergency Treatment room and Respiratory Therapy areas were observed and reviewed at 5:05 p.m. on July 5, 2011. The Emergency Treatment room is a critical care area, the Respiratory Therapy (RT) area is considered a noncritical care area, these two areas are on the same zone valve. The zone valve was labeled Emergency Room (ER), but also controlled the oxygen which was being used for RT. These two different care areas can not be on the same zone valve. (See K 140 for additional information)

Based on observations and record review made on July 5 and 6, 2011, the facility failed to assure that:
- all critical care areas of the hospital had area alarms for the medical gas system,
- zone valves have a pressure gauge downstream to indicate pressure in the line,
- proper labeling was provided for all gas valves,
- zone valves were not located behind normally open or closed doors, and
- there were no master alarm panels to supervise potential system failures.

The examples in this case were:

In accordance with 4-3.1.2.2 (c) (1) of NFPA 99 (1999 Edition); area alarms shall be provided for each medical gas piping system supplying anesthetizing locations and other vital life support and critical care areas such as post anaesthesia recovery, intensive care units, and coronary care units.

In accordance with 4-3.1.2.2 (b) (1) - (3) of NFPA 99 (1999 Edition);
1. A master alarm system shall be provided to monitor the operation and condition of the source of supply, the reserve (if any), and the pressure of the main lines of all medical gas piping systems.
2. The master alarm system shall consist of two or more alarm panels located in two separate locations. One panel shall be located in the principal working area of the individual responsible for the maintenance of the medical gas piping systems and one or more panels shall be located to assure continuous surveillance during the working hours of the facility (e.g., the telephone switchboard, security office, or other continuously staffed location).
3. Each master alarm panel shall include visual indicators for each of the following conditions:
a. * A separate indicator shall be provided for all systems supplied by a manifold or an alternating-type bulk system that has as part of its normal operation a changeover from one portion of the operating supply to another portion. It shall indicate when, or just before, this changeover occurs.
b. * Where a manifold or bulk supply consists of one or more units that continuously supply the piping system while another unit remains as the reserve supply and operates only in case of an emergency, it shall be indicated separately for each system when, or just before, this changeover occurs.
c. * Where check valves are not provided for each cylinder lead of the reserve supply for a manifold or bulk supply system, it shall be indicated separately for each system when the reserve supply is reduced to one average day ' s supply. If check valves are provided in each cylinder lead, this signal is not required.
d. When a cryogenic liquid storage unit is used as a reserve for a bulk supply system, it shall be indicated separately for each system when the contents of the reserve is reduced to one average day ' s supply and when the gas pressure available in the reserve unit is reduced below the pressure required to function properly.
e. * It shall be indicated separately for each medical gas piping system when the pressure in the main line increases 20 percent or decreases 20 percent from the normal operating pressure. The actuating switch for these signals shall be installed in the main line immediately downstream (on the piping distributing side) of the main line shutoff valve or the source valve if the main line shutoff valve is not required.
f. Each of the individual alarms required in 4-3.1.2.2(d)1 shall be indicated. This shall be either by a separate indicator for each condition monitored or with a single indicator labeled " Medical Air System Fault " or similar wording and that indicates when any of the conditions monitored occurs.
g. A separate indicator shall be provided for dew point per 4-3.1.2.2(d)2.

In accordance with 4-3.1.2.3 (c) (2) of NFPA 99 (1999 Edition); area alarm panels shall be located at the nurses' station or other location that will provide for responsible surveillance.

In accordance with Section 4-3.1.2.3 (c) (3) of NFPA 99 (1999 Edition); area alarms shall indicate if the pressure in the local line increases 20 percent or decreases 20 percent from normal line pressure.

In accordance with Section 4-3.1.2.3 (e) (2) of NFPA 99 (1999 Edition); an appropriately identified pressure gauge, connected to the line being monitored, shall be installed at each area alarm panel location. It shall be appropriately labeled and shall be readily visible from a standing position.

In accordance with Section 4-3.1.2.3 (i) of NFPA 99 (1999 Edition); manual shutoff valves in boxes shall be installed where they are visible and accessible at all times. The boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.

In accordance with Section 4-3.1.2.3 (n) of NFPA 99 (1999 Edition); a shutoff valve shall be located outside each anesthetizing location in each medical gas line, so located as to be readily accessible at all times for use in an emergency. These valves shall be so arranged that shutting off the supply of gas to any one operating room or anesthetizing location will not affect the others. Valves shall be of an approved type, mounted on a pedestal or otherwise properly safeguarded against physical damage, and marked in accordance with 4-3.5.4.2.

1. The zone valve across from the Recovery room was examined at 4:50 p.m. on July 5, 2011.

a) The Critical Care Area does not have an Area Alarm, and
b) There were no Gauges on the Valve to monitor the pressures.

2. The zone valve inside the Endoscopy Cleaning room was examined at 4:57 p.m. on July 5, 2011. This valve serves the Endoscopy and Sleep Study areas.

a) The zone valves are inside a room and behind a normally open or closed door, and
b) There were no Gauges on the Valve to monitor the pressures

3. The zone valve to the left of the Emergency Room (ER) Treatment Room which serves ER-1 was examined at 5:00 p.m. on July 5, 2011. The Critical Care Area does not have an Area Alarm

4. The zone valve to the left of Respiratory Therapy which serves Respiratory Therapy and ER Treatment was examined at 5:05 p.m. on July 5, 2011.

a) The Critical Care Area does not have an Area Alarm, and
b) The Valve is incorrectly labeled for the gases, and
c) the Valve is not labeled for the Area Served as the valve controls a Critical Care Area and a Non Critical Care Area, i.e.: ER Treatment and Respiratory Therapy.

5. The zone valve to the left of the DEXA room near X-Ray was observed at 5:08 p.m. on July 5, 2011.

a) The zone valve was not labeled for the gases is served, and
b) There was no Gauge on the Valve to monitor pressures.

6. The zone valve by the Doctors entrance to Surgery which serves Surgery Room A was observed at 5:10 p.m. on July 5, 2011.

a) The Critical Care Area does not have an Area Alarm, and
b) There were no Gauges on the Valve to monitor pressures.

7. The zone valve to the right of the entrance to Surgery Room B was observed at 5:12 p.m. on July 5, 2011.

a) The Critical Care Area does not have an Area Alarm, and
b) There were no Gauges on the Valve to monitor pressures.

8. The zone valve to the left of room 101 which served Intensive Care Rooms 101 and 102 was observed at 5:20 p.m. on July 5, 2011. The Critical Care Area does not have an Area Alarm.

9. The Medical Gas Piping and Vacuum System Annual Preventive Maintenance Verification Report which was dated March 8, 2011, was reviewed for compliance. The report identified several immediate concerns which may pose hazards to patients/residents. The report identified that there were no Master Alarm Panels monitoring the condition of the source supplies in order to warn personnel of a potential failure until the pressure levels of the source have reached a point they may no longer be adequate for patient use.

Based on observations made on July 5 and 6, 2011, the facility failed to maintain the electrical system in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition and interpretations from the Centers for Medicare and Medicaid Services (CMS).

The findings include:

Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4 (b)(3) of NFPA 70. In accordance with UL listing for power strips (relocatable power taps as identified under UL standard 1363 and listings starting with XBYS) there must be a reset or test button identified for the circuit breaker to be reset.

1. The Accounting office was observed at 2:00 p.m. on July 5, 2011. A white extension cord was found under a desk in use.

2. The Medical Records storage area had a surge cord plugged into another surge cord as observed at 2:10 p.m. on July 5, 2011.

3. The Housekeeping Supervisors office had an orange extension cord in use to a camera located above the ceiling tile as observed at 2:15 p.m. on July 5, 2011.

In accordance with Article 110-13(a) of NFPA 70, electrical equipment shall be firmly secured to the surface on which it is mounted.

4. The Business office had two separate surge cords which did not rest entirely on the floor but were dangling in air and not supported properly as observed at 4:40 p.m. on July 5, 2011.

5. The Sleep Study office had a surge cord which was not supported properly, but was dangling in air as observed at 4:45 p.m. on July 5, 2011.