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 5.1.3.3.2 and 5.1.3.3.3. >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)
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Observations: Name: MAIN BUILDING 01 - Component: 01 - Tag: 0923
Based on observation and interview, it was determined the facility failed to maintain protection of cylinder and container storage areas, affecting 1 of three levels.
Findings Include:
Observation made on January 10, 2024, at 11:55 a.m., revealed there was an exterior wood shed used for oxygen storage against the building. Sprinkler protection was not provided at this location. In addition, the cylinders were not protected from the elements.
Exit Interview with the Facility Administrator, Director of Maintenance and the Regional Director of Facilities on January 10, 2024, at 2:15 p.m., confirmed the current location of oxygen storage.
| | Plan of Correction - To be completed: 03/10/2024
1. Oxygen storage space has been relocated away from the exterior wooden shed and is protected from the elements . 2. NHA/Designee will in-service Director of Maintenace regarding storage of oxygen must be relocated away from wooden sheds and protected from the elements. 3. Director of Maintenance to randomly audit that oxygen will be located away from wooden shed and protected from the elements. 4. Director of Maintenace will report findings to monthly QAPI meetings x3 month.
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