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.

COFFEYVILLE REGIONAL MEDICAL CENTER, INC 1400 W 4TH ST COFFEYVILLE, KS 67337 Nov. 24, 2020
VIOLATION: Egress Doors Tag No: K0222
Based on observation and staff interview, the facility failed to provide egress door locks that will unlock with a single motion. This deficient practice affects patients and staff in one of 12 smoke zones. This facility has a capacity of 47 with a census of 13 at the time of this survey.

Findings Include:

Observation on 11/24/20 at 10:00 AM showed the door to the Obstetrics (OB) Cesarean (C) section room has a thumb turn lock in use on the exit door.

Staff Facility Maintenance Director (FMD) and Director of Quality Improvement (DQI) were present and acknowledged the findings.

Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
VIOLATION: Stairways and Smokeproof Enclosures Tag No: K0225
Based on observation and staff interview, the facility failed to maintain their stairway enclosures as required in Life Safety Code 101. The deficient practice could affect patients, staff and visitors in all smoke zones. The facility has a capacity of 47 with a census of 13 at the time of the survey.

Findings Include:

1. Observation on 11/24/20 at 11:00 AM in the east stairs by the emergency room (ER) above the ceiling on the south wall there are (3) - 1-inch penetrations into the stairwell.
2. Observation on 11/24/20 at 2:16 PM in the basement above the door to the southeast stairwell, there is a single layer of sheetrock from the top of the door to the ceiling. The code footprint shows this wall as a 2-hour fire wall.
3. Observation on 11/24/20 at 2:33 PM in the basement above the ceiling in wall to the ER stairwell there is a 1-inch penetration.

Staff Facility Maintenance Director (FMD) and Director of Quality Improvement (DQI) were present and acknowledged the findings.


NFPA Standard: Life Safety Code 101 2012 7.2.2 Stairs. 7.2.2.1 General. 7.2.2.1.1 Stairs used as a component in the means of egress shall conform to the general requirements of Section 7.1 and
to the special requirements of 7.2.2, unless otherwise specified in 7.2.2.1.2. 7.2.2.5.1.1 All inside stairs serving as an exit or exit component shall be enclosed in accordance with 7.1.3.2. 7.1.3.2 Exits.
7.1.3.2.1 Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following: (1)*The separation shall have a minimum 1-hour fire resistance rating where the exit connects three or fewer stories. (2) The separation specified in 7.1.3.2.1(1), other than an existing separation, shall be supported by construction having not less than a 1-hour fire resistance rating. (3)*The separation shall have a minimum 2-hour fire resistance rating where the exit connects four or more stories, unless one of the following conditions exists: (a) In existing non-high-rise buildings, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. (b) In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. (c) The minimum 1-hour enclosures in accordance
with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative to the requirement of 7.1.3.2.1(3). (4) Reserved. (5) The minimum 2-hour fire resistance-rated separation
required by 7.1.3.2.1(3) shall be constructed of an assembly of noncombustible or limited-combustible materials and shall be supported by construction having a minimum 2-hour fire resistance rating, unless otherwise permitted by 7.1.3.2.1(7). (6)*Structural elements, or portions thereof, that support
exit components and either penetrate into a fire resistance-rated assembly or are installed within a fire
resistance-rated wall assembly shall be protected, as a minimum, to the fire resistance rating required by 7.1.3.2.1(1) or (3). (7) In Type III, Type IV, and Type V construction, as defined in NFPA220, Standard on Types of Building Construction (see 8.2.1.2), fire-retardant-treated wood enclosed in noncombustible
or limited-combustible materials shall be permitted. (8) Openings in the separation shall be protected by fire door assemblies equipped with door closers complying with 7.2.1.8. (9)*Openings in exit enclosures shall be limited to door assemblies from normally occupied spaces and corridors and door assemblies for egress from the enclosure, unless one of the following conditions exists: (a) Openings in exit passageways in mall buildings as provided in Chapters 36 and 37 shall be permitted. (b) In buildings of Type I or Type II construction, as defined in NFPA 220, Standard on Types of Building Construction (see 8.2.1.2), existing fire protection- rated door assemblies to interstitial spaces shall be permitted, provided that such spaces meet all of the following criteria: i. The space is used solely for distribution of pipes, ducts, and conduits. ii. The space contains no storage. iii. The space is separated from the exit enclosure in accordance with Section 8.3. (c) Existing openings to mechanical equipment spaces
protected by approved existing fire protection- rated door assemblies shall be permitted, provided
that the following criteria are met: i. The space is used solely for non-fuel-fired mechanical equipment.
ii. The space contains no storage of combustible materials. iii. The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. (10) Penetrations into, and openings through, an exit enclosure assembly shall be limited to the following: (a) Door assemblies permitted by 7.1.3.2.1(9) (b)*Electrical conduit serving the exit enclosure (c) Required exit door openings (d) Ductwork and equipment necessary for independent stair pressurization (e) Water or steam piping necessary for the heating or cooling of the exit enclosure (f) Sprinkler piping (g) Standpipes
(h) Existing penetrations protected in accordance with 8.3.5
(i) Penetrations for fire alarm circuits, where the circuits are installed in metal conduit and the penetrations are protected in accordance with 8.3.5 (11) Penetrations or communicating openings shall be prohibited between adjacent exit enclosures. (12) Membrane penetrations shall be permitted on the exit access side of the exit enclosure and shall be protected in accordance with 8.3.5.6. 8.3.5.6.1 Membrane penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through membrane of a wall, floor, or floor/ceiling assembly constructed
as a fire barrier shall be protected by a firestop system or device and shall comply with 8.3.5.1 through 8.3.5.5.2.
VIOLATION: Hazardous Areas - Enclosure Tag No: K0321
Based upon observation and staff interview, the facility failed to ensure that hazardous areas are separated from other spaces by smoke resisting partitions and doors. The deficient practice fails to provide solid, smoke resisting walls or ceiling in hazardous areas which would not stop the spread of smoke, affecting all patients, visitors and staff in all smoke zones. The facility has a capacity of 47 with a census of 13 at the time of this survey.

Findings Include:

1. Observation on 11/24/20 at 9:20 AM in the 2nd floor oxygen storage room there is a 1 inch diameter hole through the south wall by the junction box.
2. Observation on 11/24/20 at 9:29 AM the door to the 2nd floor soiled utility room is missing the door hardware. This leaves a 2 inch penetration in the door.
3. Observation on 11/24/20 at 10:46 AM in the emergency room (ER) soiled utility room above the ceiling the sprinkler piping passing through the north and south walls are not sealed.

Staff Facility Maintenance Director (FMD) and Director of Quality Improvement (DQI) was present and acknowledged the findings.

NFPA Standard: Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4-hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. 2012 NFPA 101 19.3.2.1
VIOLATION: Cooking Facilities Tag No: K0324
Based on record review and staff interview, the facility failed to provide proper ventilation and fire protection of commercial cooking operations in accordance with NFPA 96. This deficient practice affects all patients, visitors and staff in one of 12 smoke zones. The facility has a capacity of 47 with a census of 13 at the time of survey.

Findings Include:

1. Observation on 11/24/20 at 9:53 AM in the Obstetrics (OB) department there is a kitchenette installed that is open to the corridor. No ventilation or suppression system is installed. No interlock device is present to shut off power when not in use.

Staff Facility Maintenance Director (FMD) and Director of Quality Improvement (DQI) was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Within a smoke compartment, where residential or commercial cooking equipment is used to prepare meals for 30 or fewer persons, one cooking facility shall be permitted to be open to the corridor, provided that all of the following conditions are met:
(1) The portion of the health care facility served by the cooking facility is limited to 30 beds and is separated from other portions of the health care facility by a smoke barrier constructed in accordance with 19.3.7.3, 19.3.7.6, and 19.3.7.8.
(2) The cooktop or range is equipped with a range hood of a width at least equal to the width of the cooking surface, with grease baffles or other grease-collecting and cleanout capability.
(3)*The hood systems have a minimum airflow of 500 cfm (14,000 L/min).
(4) The hood systems that are not ducted to the exterior additionally have a charcoal filter to remove smoke and odor.
(5) The cooktop or range complies with all of the following:
(a) The cooktop or range is protected with a fire suppression system listed in accordance with UL 300, Standard for Fire Testing of Fire Extinguishing Systems for Protection of Commercial Cooking Equipment, or is tested and meets all requirements of UL 300A, Extinguishing System Units for Residential Range Top Cooking Surfaces, in accordance with the applicable testing document's scope.
(b) A manual release of the extinguishing system is provided in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, Section 10.5.
(c) An interlock is provided to turn off all sources of fuel and electrical power to the cooktop or range when the suppression system is activated.
(6) The use of solid fuel for cooking is prohibited.
(7) Deep-fat frying is prohibited.
(8) Portable fire extinguishers in accordance with NFPA 96 are located in all kitchen areas.
(9) A switch meeting all of the following is provided:
(a) A locked switch, or a switch located in a restricted location, is provided within the cooking facility that deactivates the cooktop or range.
(b) The switch is used to deactivate the cooktop or range whenever the kitchen is not under staff supervision.
(c) The switch is on a timer, not exceeding a 120-minute capacity that automatically deactivates the cooktop or range, independent of staff action.
(10) Procedures for the use, inspection, testing, and maintenance of the cooking equipment are in accordance with
Chapter 11 of NFPA 96 and the manufacturer's instructions and are followed.
(11) Not less than two AC powered photoelectric smoke alarms, interconnected in accordance with 9.6.2.10.3 equipped with a silence feature, and in accordance with NFPA 72, National Fire Alarm and Signaling Code, are located not closer than 20 ft. (6.1 m) from the cooktop or range.
(12) No smoke detector is located less than 20 ft. (6.1 m) from the cooktop or range.
(13) The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. 2012 NFPA 101, 19.3.2.5.3
VIOLATION: Fire Alarm System - Testing and Maintenance Tag No: K0345
Based on observation, interview and record review, the facility failed to maintain and test the fire alarm system in accordance with NFPA 72. Failure to maintain the fire alarm system in accordance with NFPA 72 can prevent the system from working as designed, components and initiating devices from working as designed and delaying notification of patients, visitors and staff in the event of a fire affecting all patients, visitors and staff in all smoke zones. The facility has a capacity of 47 with a census of 13 at the time of this survey.

Findings Include:

1. Observation on 11/24/20 at 9:49 AM in the Obstetrics (OB) waiting room the smoke detector is installed in the direct air flow of the vent.
2. Observation on 11/24/20 at 11:01 AM in the emergency room (ER) waiting room the pull station is obstructed by furniture.
3. Observation on 11/24/20 at 12:44 PM in the Operating Room (OR) Two the smoke detector is installed in the direct air flow of the vent.
4. Observation on 11/24/20 at 12:59 PM in Central Sterile clean side the west smoke detector is installed in the direct air flow of the vent.
5. Observation on 11/24/20 at 1:28 PM in the Computerized Tomography (CT) closet there are missing ceiling tiles around the smoke detector.
6. Observation on 11/24/20 at 2:02 PM in the Physical Therapy (PT) room by the offices the smoke detector is installed in the direct air flow of the vent.
7. Observation on 11/24/20 at 2:46 PM in the basement switch gear room the smoke detectors are installed 6 ft below the ceiling.

Staff Facility Maintenance Director (FMD) and Director of Quality Improvement (DQI) was present and acknowledged the findings.

NFPA Standard: A fire alarm system required for life safety shall be installed, tested , and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101, 9.6.1.3

NFPA Standard: 17.7.1.7 The selection and placement of smoke detectors shall take into account both the performance characteristics of the detector and the areas into which the detectors are to be installed to prevent nuisance alarms or improper operation after installation.
17.7.1.8* Unless specifically designed and listed for the expected conditions, smoke detectors shall not be installed if
any of the following ambient conditions exist:
(1) Temperature below 32F (0C)
(2) Temperature above 100F (38C)
(3) Relative humidity above 93 percent
(4) Air velocity greater than 300 ft/min (1.5 m/sec)
17.7.1.9* The location of smoke detectors shall be based on an evaluation of potential ambient sources of smoke, moisture, dust, or fumes, and electrical or mechanical influences, to minimize nuisance alarms.
VIOLATION: Sprinkler System - Maintenance and Testing Tag No: K0353
Based on observation, record review and interview the facility failed to ensure that the automatic sprinkler system is installed, maintained and tested in accordance with NFPA 25. This deficient practice fails to ensure that the sprinkler system will be properly prepared in the event of a fire, affecting all patients, visitors and staff in all smoke zones. The facility has a capacity of 47 and census of 13 at the time of the survey.

Findings Include:

1. Observation on 11/24/20 at 12:56 PM in the Central Sterile dirty side, the sprinkler head is missing the escutcheon (a flat piece of metal for protection).
2. Observation on 11/24/20 at 2:57 PM in the air handler room, the sprinkler riser is obstructed by a desk.
3. Document review on 11/24/20 at 3:07 PM showed there is no documentation of the testing or replacement of sprinkler gauges installed in the facility on all sprinkler systems. The sprinkler system gauges were dated 2014.
4. Document review on 11/24/20 at 3:23 PM showed there is no documentation of the 20 year testing of the quick response sprinkler heads installed in the facility. The sprinkler heads that were found were dated 1999.

Staff Facility Maintenance Director (FMD) and Director of Quality Improvement (DQI) was present and acknowledged the findings.

Review of the following NFPA Standard revealed: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2012 NFPA 101, 9.7.5 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.

Review of the following NFPA Standard revealed: Sprinklers shall be inspected from the floor level annually. 2011 NFPA 25, 5.2.1.1
VIOLATION: Subdivision of Building Spaces - Smoke Barrie Tag No: K0372
Based upon observation and staff interview, the facility failed to ensure that smoke barriers are constructed to a minimum 1/2 hour fire resistance rating. This deficient practice would not prevent the passage of smoke or fire to other areas of the building, affecting all patients, visitors and staff in six of 12 smoke zones. The facility has a capacity of 47 with a census of 13 at the time of this survey.

Findings Include:

1. Observation on 11/24/20 at 8:49 AM by room 260 above the ceiling, there is a 1 inch conduit that is unsealed passing through the smoke barrier.
2. Observation on 11/24/20 at 9:08 AM by room 236 above the ceiling, there are (2) - 2 inch penetrations in the smoke barrier with communications wiring passing through that is unsealed.
3. Observation on 11/24/20 at 11:06 AM above the ceiling in the emergency room (ER) waiting room, there is a 2 foot (ft) by 2 ft section of sheetrock missing from the east smoke barrier.
4. Observation on 11/24/20 at 11:13 AM in the corridor north of the ER lobby above the ceiling, there is a 1 inch conduit passing through the north smoke barrier that is unsealed.
5. Observation on 11/24/20 at 1:17 PM above the ceiling along the east wall to the x ray room, there are multiple penetrations throughout the entire length of the smoke barrier.

Staff Facility Maintenance Director (FMD) and Director of Quality Improvement (DQI) was present and acknowledged the findings.

NFPA Standard: Smoke barriers shall be constructed to a 1/2 hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
VIOLATION: Fire Drills Tag No: K0712
Based on record review and staff interview, the facility failed to conduct fire drills as required and properly record the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting patients, visitors and staff in all smoke zones. The facility has a capacity of 47 and a census of 13.

Findings Include:

1. Documentation review of the fire drills for the previous five quarters on 11/23/20 at 11:00 AM showed the facility failed to complete fire drills in 2020 for 3rd shift during the 2nd quarter, 1st shift during the 2nd quarter and 2nd shift during the 3rd quarter.

Staff Facility Maintenance Director (FMD) and Director of Quality Improvement (DQI) was present and acknowledged the findings.

Review of the following NFPA Standard revealed: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1. A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center. Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. Employees of health care occupancies shall be instructed in life safety procedures and devices. 2012 NFPA 101, 19.7.1.1-8
VIOLATION: Gas and Vacuum Piped Systems - Inspection and Tag No: K0908
Based on observation, interview, and review of records, the hospital failed to ensure that the medical gas system is maintained in accordance with the National Fire Protection Association (NFPA) 99 which resulted in an Immediate Jeopardy (IJ a situation in which the providers noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairments or death to a patient) finding. This deficient practice failed to ensure patients are protected from unacceptable levels of carbon monoxide (CO) and to provide patients with the minimum amount of medical gas flow from outlets. The deficient practice affects all patients throughout the hospital. The facility has 47 certified beds and at the time of the survey had a census of 13 patients.

Findings Include:

Documentation review on 11/23/20 at 1:00 PM of the annual Medical (Med) Gas Testing Report from a medical gas testing company dated 06/04/20 showed the following deficiencies:

1. Medical Gas Compressor Failed Bad Carbon Monoxide (CO a colorless, odorless, and tasteless flammable gas that can be toxic) Sensor.
2. Medical Gas Compressor Failed Source valve not installed in proper location.
3. Vacuum Pump Failed Gas specific demand check valves are not installed on the main line, source pressure switch and gauge.
4. Med Gas Manifold Source valve is not installed in the proper location and labeled.
5. Thirteen outlets for the Medical Gas systems failed:
Operating Room (OR)1 vacuum drop outlet failed minimum flow test
OR1 vacuum wall outlet failed minimum flow test
OR2 vacuum boom outlet failed minimum flow test
OR2 nitrous oxide wall outlet failed minimum flow test
OR3 vacuum drop outlet failed minimum flow test
OR3 vacuum wall outlet failed minimum flow test
Oncology oxygen wall outlet leaking failedOncology vacuum wall outlet leaking failed
emergency room (ER) 4 oxygen wall outlet leaking failed
Room 220 oxygen wall outlet 1 leaking failed
Room 220 oxygen wall outlet 2 leaking failed
Room 229 oxygen wall outlet leaking failed
Room 240 vacuum wall outlet leaking failed

The facility received this inspection report on 06/25/20.

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

During an interview on 11/23/20 at 1:05 PM, the Facility Maintenance Director (FMD) said that he had been in contact with a med gas repair contractor. The FMD indicated that the facility had no documentation of the repairs being completed. The medical gas testing company was contacted by the FMD at 1:30 PM. The medical gas testing company will have a repair tech onsite by 6:30 PM on 11/23/20 to make repairs.

The facility/Director of Quality Improvement (DQI) were notified at 5:26 PM on 11/23/20 that these deficiencies represent an Immediate Jeopardy.

The repair technician arrived at approximately 6:30 PM on 11/23/20 and worked until 1:00 AM installing and calibrating a new CO sensor and repairing med gas outlets that failed the pressure testing. Patient rooms 220, 229 and 240 could not be repaired by the repair tech at this time.

The hospital removed the IJ on 11/24/20 at 5:12 PMwhen they submitted a plan to move patients out of Patient rooms 220, 229 and 240.

The plan of removal also included the following:
The repair technician will return the week of 11/30/20 to repair the med gas outlets in Patient rooms 220, 229 and 240.
The facility has moved patients out of rooms 220, 229 and 240 until repairs are completed. The rooms are marked out of service and staff has been notified.
Once repairs are completed the facility will submit documentation of repairs to the Office of the State Fire Marshal.

Review of the following NFPA Standard revealed:
Medical Air Systems shall have operational pressure testing for their piped medical air systems.(NFPA 99) 5.1.12.3.10 Review of the following NFPA Standard revealed: 5.1.12.3.10 Operational Pressure Test. Operational
pressure tests shall be performed at each station outlet/inlet or terminal where the user makes connections and disconnections.
5.1.12.3.10.1 Tests shall be performed with the gas of system designation or the operating vacuum.
5.1.12.3.10.2 All gas outlets with a gauge pressure of 345 kPa (50 psi), including, but not limited to,
oxygen, nitrous oxide, medical air, and carbon dioxide, shall deliver 100 SLPM (3.5 SCFM) with a
pressure drop of not more than 35 kPa (5 psi) and static pressure of 345 kPa to 380 kPa (50 psi to 55
psi).
VIOLATION: Electrical Equipment - Power Cords and Extens Tag No: K0920
Based on observation and staff interview, the facility did not ensure that electrical wiring and equipment is installed and maintained in accordance with NFPA 99, Health Care Facility Code. This deficient practice does not ensure prevention of an electrical fire or electric shock hazard, affecting patients, visitors and staff in one of 12 smoke zones. This facility has a capacity of 47 with a census of 13 at the time of this survey.

Findings Include:

Observation on 11/24/20 at 1:05 PM, the 1363A medical grade power strips located in the Operating Room (OR) are fastened to med carts with a thumb turn screw. No tools are required to remove the power strips.

Staff Facility Maintenance Director (FMD) and Director of Quality Improvement (DQI) were present and acknowledged the findings.

NFPA Standard: Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 2012 NFPA 101, 9.1.2

NFPA Standard: Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL -1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

NFPA Standard: NFPA 99 10.2.3.6 Multiple Outlet Connection. Two or more power receptacles supplied by a flexible cord shall be permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, pedestal-, or cartmounted, provided that all of the following conditions are met:
(1) The receptacles are permanently attached to the equipment assembly.
(2)*The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets.
(3) The ampacity of the flexible cord is in accordance with NFPA 70, National Electrical Code.
(4)*The electrical and mechanical integrity of the assembly is
regularly verified and documented.
(5)*Means are employed to ensure that additional devices or nonmedical equipment cannot be connected to the multiple outlet extension cord after leakage currents have been verified as safe.