|Gas Equipment - Cylinder and Container Storage|
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 184.108.40.206.2 and 220.127.116.11.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923
Based on observation and interview, it was determined the facility failed to properly store oxygen cylinders in one instance, affecting one of ten smoke compartments.
1. Observation on May 13, 2019, at 9:49 a.m., revealed an aggregate volume of oxygen greater than 300 cubic feet was being stored in the employee entrance hallway, outside of an approved oxygen storage area.
Interview with the Facility Administrator and Maintenance Director on May 13, 2019, at 1:30 p.m., confirmed more than 300 cubic feet of oxygen was being stored outside of an approved oxygen storage area.
| ||Plan of Correction - To be completed: 06/26/2019|
"The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein."
The Oxygen Cylinders have been removed from the employee entrance hall.
Plans will be submitted to Health Facility Plan Reviewer for the development of an additional Oxygen Storage in accordance with 18.104.22.168.2 and 22.214.171.124.3
Prior to any further construction Oxygen cylinders will be stored appropriately per NFPA guidelines.
Random audits of Oxygen Cylinder Storage areas for compliance with regulations will be conducted by the Maintenance Director or designee weekly x 4 weeks, then monthly x 2 months. Identified trends will be reviewed by the QA&A committee for appropriate follow up monthly.