The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

HORTON COMMUNITY HOSPITAL 240 WEST 18TH STREET HORTON, KS 66439 May 27, 2015
VIOLATION: PHYSICAL PLANT AND ENVIRONMENT Tag No: C0910
Based on document review and Life Safety Code complaint investigation findings, the Critical Access Hospital (CAH) failed to meet the applicable provisions of the current Life Safety Code (refer to C-231) when they failed to respond to a medical gas survey completed by an outside company in July of 2014 that revealed several deficiencies that could result in the following: an oxygen rich environment or oxygen poor environment, leaking that could pose a hazard to anyone in the vicinity, especially if an anesthetic gas like nitrous oxide is involved, and potential failure to alert staff to rises/falls in levels above/below required pressures.

These deficiencies resulted in the Life Safety Code inspector of the state fire marshal's office notifying the facility's administration that the Centers for Medicare and Medicaid Services identified this as an Immediate Jeopardy situation on May 27, 2015 at 8:29am that was not removed at exit.
VIOLATION: LIFE SAFETY FROM FIRE Tag No: C0930
Based on document review and LSC complaint inspection findings, the Critical Access Hospital (CAH) failed to comply with piped in medical gas systems that comply with NFPA (National Fire Protection Agency) 99, Chapter 4. The deficient practice resulted in a situation that could adversely affect all patients in two of two smoke zones using or receiving medical gas from the bulk medical gas system throughout and within all areas of the facility including the Emergency Department (ED), Operating Rooms (ORs), and patient care areas.


Findings include:


The facility had a capacity of 25 and a current census of four at the time of the state fire marshal's original survey on 5/12/15.

The state fire marshal's review on May 22, 2015 of the Medical Piped Gas Inspection conducted by Complaint Healthcare Technologies LLC dated July 9, 2014 revealed the following deficiencies:

1. Master alarms are missing signals from the oxygen manifold.
2. The oxygen manifold is missing many key components.
3. Many of the zone valves do not have gauges.
4. Many of the vacuum valves are missing.
5. The emergency department and outpatient surgery are missing area alarms.
6. The terminal deficiencies include leaking outlets, vacuum with low flow and damaged release buttons.

NFPA 99 Standard Chapter 4 read (in part): Manifold, piping, valving, controls, outlets/terminals, alarms shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. 2000 NFPA 101, 19.3.2.4.

See the results of the LSC (Life Safety Code) complaint survey dated 5/27/2015 (ASPEN #YSCL21) for additional information.