|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 220.127.116.11.2 and 18.104.22.168.3.
>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 maintain oxygen cylinder storage, affecting one of four floors.
1. Observation on February 24, 2020, at 12:30 p.m., revealed there was a freestanding E-size oxygen cylinder inside the 1st floor oxygen storage room.
Interview at the exit conference with the Administrator and Maintenance Director on February 24, 2020, at 2:45 p.m., confirmed the cylinder was not secured.
| ||Plan of Correction - To be completed: 04/14/2020|
The oxygen cylinder was secured in a carrier.
To ensure the facility maintains oxygen cylinder storage by properly securing oxygen cylinders in carriages, the Maintenance Director or Designee will conduct monthly audits of oxygen storage.
The audits will be documented, and the results reported to QAPI for 3 months.