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.

SEDAN CITY HOSPITAL 300 NORTH STREET SEDAN, KS 67361 Dec. 1, 2020
VIOLATION: PHYSICAL PLANT AND ENVIRONMENT Tag No: C0910
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on the life safety code (LSC) complaint survey (KS 449; ASPEN #GCVS21) findings, the critical access hospital failed to meet the requirements for Life Safety from Fire and the National Fire Protection Association (NFPA) Standard 101, 2012 edition when they the hospital failed to ensure that the medical gas system is maintained in accordance with the NFPA 99, the hospital failed to ensure that the generator is installed and monitored in accordance with the NFPA 99 and NFPA 110, and the hospital failed to ensure that the generator is tested and its equipment functions in accordance with the NFPA 110.

These deficient practices failed to ensure patients are being provided with the minimum amount of medical gas flow from the wall outlet in two of 25 rooms (Rooms 203 and 209); failed to ensure that the hospital had an annunciator panel for the generator; and failed to ensure a reliable source of emergency power would be delivered to the hospital's life safety systems during a loss of power.


Findings Include:


1. Review of the annual Medical (Med) Gas Testing Report dated 06/02/20 showed the following deficiencies:

Medical Gas Outlet in room 203 low minimum flow due to possible obstruction of the outlet.
Medical Gas Outlet in room 209 low minimum flow due to possible obstruction of the outlet.

There is no documentation that the facility repaired or replaced either of the outlets since receiving this inspection report.

The Facility Maintence Director (FMD) was notified at 3:30 PM on 11/03/20 that these deficiencies represent an Immediate Jeopardy.

The hospital removed the IJ on 11/03/20 at 3:41 PM when they submitted a plan to close rooms 203 and 209 to patients and to notify staff that those rooms were out of service until the med gas outlets were repaired.

The plan of removal also included the following:
The med gas repair company will arrive at Sedan City hospital on [DATE].
The Identified Deficiencies will be repaired and in full compliance. The Identified deficiencies include the low flow of medical gas in patient rooms 203 and 206.
Once the repairs are made the med gas repair company will provide the hospital with a full report that documents the corrections.
Once the report is received by the hospital, it will be reported immediately to the Kansas State Fire Marshal Office.

(Refer to C-0930 and LSC Report #GCVS21, K-908 for further details)

2. Interview with the FMD on 11/03/20 at 3:54 PM revealed the emergency generator located in the lower level boiler room does not have a remote annunciator panel installed. Not having a annunciator panel installed that is connected to the generator would prevent staff from being notified when the generator was in trouble. The generator provides backup emergency power to the emergency and exit lighting, all red outlets and switches and everything in (2) emergency room s.

The Facility Maintenance Director and the Administrator were notified at 2:00 PM on 11/04/20 that failure to provide the remote annunciator panel for the generator that provides emergency power to the hospital, in order to ensure the power source is reliable in an emergency, represents an Immediate Jeopardy.

The hospital removed the IJ on 11/04/20 at 5:00 PM when they submitted a plan to place an employee in the generator room 24/7 until an annunciator panel could be installed. This employee will be in radio contact with the nurse station.
The plan of removal also included the following:
Hospital staff will be performing a monthly load test and all weekly checks on the generator daily.
Hospital staff will be stationed in the generator room 24/7 until annunciator panel is installed. Staff at the generator will be in radio contact with the nurse station.
The generator repair contractor will be at the facility no later than 11/13/20 to install an annunciator panel at the nurse station for the generator.

(Refer to C-0930 and LSC Report #GCVS21, K-916 for further details)


3. On 11/03/20 at 11:10 AM during documentation review, the facility failed to document the amperage and voltage of monthly generator tests.
On 11/03/20 at 11:12 AM during documentation review, the facility failed to perform a 36 month 4 hour load bank test on the natural gas powered emergency generator.

Observation on 11/03/20 at 10:43 AM during a generator load test, the gauges located on the transfer switch failed to show any amperage being produced by the generator. The generator ran for 15 minutes and the maintenance director used the transfer switch to start the test. During the generator test there are no indications that the generator is powering the facility.

The FMD and the Administrator were notified at 2:00 PM on 11/04/20 that failure to provide complete documentation of inspection testing and maintenance for the generator does not ensure a reliable source of emergency power is being delivered to the life safety systems during a loss of power. This deficiency represents an IJ.

The hospital removed the IJ on 11/04/20 at 5:00 PM when they submitted a plan to place an employee in the generator room 24/7 until the gauges could be replaced. This employee will be in radio contact with the nurse station.

The plan of removal also included the following:
Hospital staff will be performing a monthly load test and all weekly checks on the generator daily.
Hospital staff will be stationed in the generator room 24/7 until the gauges are repaired or replaced. Staff at the generator will be in radio contact with the nurse station. The generator repair company will be at the facility no later than 11/13/20 to repair or replace the gauges.

(Refer to C-0930 and LSC Report #GCVS21, K-918 for further details)
















































.
VIOLATION: LIFE SAFETY FROM FIRE Tag No: C0930
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on the life safety code complaint survey (KS 449; ASPEN #GCVS21) findings, the critical access hospital failed to meet the requirements for Life Safety from Fire and the National Fire Protection Association (NFPA) Standard 101, 2012 edition when they the hospital failed to ensure that the medical gas system is maintained in accordance with the NFPA 99, the hospital failed to ensure that the generator is installed and monitored in accordance with the NFPA 99 and NFPA 110, and the hospital failed to ensure that the generator is tested and its equipment functions in accordance with the NFPA 110.

These deficient practices failed to ensure patients are being provided with the minimum amount of medical gas flow from the wall outlet in two of 25 rooms (Rooms 203 and 209); failed to ensure the hospital had an annunciator panel for the generator that provides emergency power to the hospital during an emergency; and failed to ensure a reliable source of emergency power is being delivered to the hospital's life safety systems during a loss of power.


Findings Include:


1. Review of the annual Medical (Med) Gas Testing Report dated 06/02/20 showed the following deficiencies:

Medical Gas Outlet in room 203 low minimum flow due to possible obstruction of the outlet.
Medical Gas Outlet in room 209 low minimum flow due to possible obstruction of the outlet.

The regional maintenance director received this inspection report by mid June 2020.

There is no documentation that the facility repaired or replaced either of the outlets since receiving this inspection report.

The facility/Facility Maintenance Director (FMD) were notified at 3:30 PM on 11/03/20 that these deficiencies represent an Immediate Jeopardy.

The hospital removed the IJ on 11/03/20 at 3:41 PM when they submitted a plan to close rooms 203 and 209 to patients and to notify staff that those rooms were out of service until the med gas outlets were repaired.

The plan of removal also included the following:
The med gas repair company will arrive at Sedan City hospital on [DATE].
The Identified Deficiencies will be repaired and in full compliance. The Identified deficiencies include the low flow of medical gas in patient rooms 203 and 206.
Once the repairs are made the med gas repair company will provide the hospital with a full report that documents the corrections.
Once the report is received by the hospital, it will be reported immediately to the Kansas State Fire Marshal Office.


2. Interview with the facility maintenance director on 11/03/20 at 3:54 PM revealed the emergency generator located in the lower level boiler room does not have a remote annunciator panel installed. Not having a annunciator panel installed that is connected to the generator would prevent staff from being notified when the generator was in trouble. The generator provides backup emergency power to the emergency and exit lighting, all red outlets and switches and everything in (2) emergency room s.

During an interview on 11/04/20 at 11:45 AM, the FMD said that he does not remember an annunciator ever being installed. The FMD indicated that in the past there was a red light located at the nurse station that came on when the generator was on. This red light could not be located during inspection. The Administrator called the regional maintenance director for contact information for a generator repair contractor. The Administrator made contact with a generator repair contractor to schedule the installation of the annunciator panel.

The facility/FMD and the Administrator were notified at 2:00 PM on 11/04/20 that failure to provide the remote annunciator panel for the generator that provides emergency power to the hospital, in order to ensure the power source is reliable in an emergency, represents an Immediate Jeopardy.

The hospital removed the IJ on 11/04/20 at 5:00 PM when they submitted a plan to place an employee in the generator room 24/7 until an annunciator panel could be installed. This employee will be in radio contact with the nurse station.
The plan of removal also included the following:
Hospital staff will be performing a monthly load test and all weekly checks on the generator daily.
Hospital staff will be stationed in the generator room 24/7 until annunciator panel is installed. Staff at the generator will be in radio contact with the nurse station.
The generator repair contractor will be at the facility no later than 11/13/20 to install an annunciator panel at the nurse station for the generator.


3. On 11/03/20 at 11:10 AM during documentation review, the facility failed to document the amperage and voltage of monthly generator tests.
On 11/03/20 at 11:12 AM during documentation review, the facility failed to perform a 36 month 4 hour load bank test on the natural gas powered emergency generator.

Observation on 11/03/20 at 10:43 AM during a generator load test, the gauges located on the transfer switch failed to show any amperage being produced by the generator. The generator ran for 15 minutes and the maintenance director used the transfer switch to start the test. During the generator test there are no indications that the generator is powering the facility. The maintenance staff said the only way to see what the generator powers is to have an actual power outage. The generator seemed to run at or just above idle speed and there was no change in speed of the generator during the entire test. With no amperage being shown on the gauges it does not ensure the transfer switch is operating properly.

Interview on 11/04/20 at 11:45 AM, the FMD said that he does not remember the gauges working. FMD also indicated that he was unaware that during monthly load testing that amps and volts for each phase of the generator needed to be documented. The generator provides backup emergency power to the emergency and exit lighting, all red outlets and switches and everything in 2 emergency room s.

The facility/FMD and the Administrator were notified at 2:00 PM on 11/04/20 that failure to provide complete documentation of inspection testing and maintenance for the generator does not ensure a reliable source of emergency power is being delivered to the life safety systems during a loss of power. This deficiency represents an IJ.

The hospital removed the IJ on 11/04/20 at 5:00 PM when they submitted a plan to place an employee in the generator room 24/7 until the gauges could be replaced. This employee will be in radio contact with the nurse station.

The plan of removal also included the following:
Hospital staff will be performing a monthly load test and all weekly checks on the generator daily.
Hospital staff will be stationed in the generator room 24/7 until the gauges are repaired or replaced. Staff at the generator will be in radio contact with the nurse station. The generator repair company will be at the facility no later than 11/13/20 to repair or replace the gauges.

(Refer to LSC Report #GCVS21, K-908, K-916, and K-918 for further details).