Failure to Verify Oxygen Purity After Medical Gas Line Repair
Penalty
Summary
The facility failed to ensure that all 24 residents who were dependent on mechanical ventilators received oxygen that was verified to be free of contaminants after a repair to the medical gas line system. On the date of the incident, an oxygen alarm was triggered in the Subacute Unit, which led to the discovery of a broken oxygen line. The facility's census at the time included 24 residents in the Subacute Unit who were reliant on mechanical ventilation for respiratory support. Following the repair of the oxygen line by a contracted service, the facility returned the oxygen gas line to service without conducting required quality testing or verification by a certified medical gas verifier. Interviews with facility staff, including the Facilities Director and the Regional Compliance Officer, confirmed that no certified medical gas verifier was called to inspect, test, or verify the oxygen gas line after the repair. The Facilities Director, who is not certified as a medical gas verifier, made the decision to return the system to service based on his own judgment and background in electrical and biomedical engineering. The last documented oxygen gas quality testing had been performed over a month prior, and annual testing was the facility's standard practice. No documentation was available to confirm the safety, purity, or integrity of the medical gas system following the repair. The residents affected by this deficiency had significant medical histories, including chronic respiratory failure, traumatic brain injury, stroke, anoxic brain injury, and other conditions requiring continuous mechanical ventilation. Many had tracheostomies and feeding tubes, and were entirely dependent on the facility's oxygen supply for survival. Despite the critical nature of their conditions, the facility did not follow required protocols for post-repair verification of the medical gas system, as outlined in NFPA 99, which mandates thorough leak testing, purging, and functional testing by a certified third-party verifier after any repair or modification to a medical gas piping system.