|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 188.8.131.52.2 and 184.108.40.206.3.
>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 - Component: 01 - Tag: 0923
Based on observation and interview, it was determined the facility failed to segregate oxygen cylinders, full from empty, affecting one of two floors within the component.
1. Observation on February 5, 2020, at 11:31 AM revealed three oxygen cylinders considered empty, commingled within a majority of oxygen cylinders considered full, within the 2nd floor Oxygen Storage Room.
Interview with the Director of Maintenance on February 5, 2020, at 11:31 AM confirmed the cylinders were not separated, full from empty.
| ||Plan of Correction - To be completed: 03/30/2020|
The facility immediately corrected the situation by separating the full and empty tanks in the Oxygen Storage Room. The Facilities Director or designee will in-service nursing staff regarding requirement to segregate empty cylinders from full cylinders. Facilities Director or designee to audit oxygen storage room weekly times 3 months to ensure that empty and full cylinders are segregated. Facilities Director or designee to monitor compliance at Quality Assurance and Performance Improvement Committee (QAPI) meeting monthly times 3 months and afterwards as necessary.