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Based on observation and interview, the facility failed to meet the medical gas storage requirements in accordance with NFPA 50, 1996 Edition, Sections 1-3 and 4-2.1. These deficiencies could affect 2 of 2 main floor smoke compartments.

Findings include:

During an observation on 9/29/15 at 11:15 a.m., the medical gas storeroom and area outside & adjacent to the storeroom was inspected. The amount of stored oxygen would qualify the area as a bulk oxygen system as it exceeded 20,000 cubic feet, on site.¹

During an interview on 9/29/15 at at 11:15 a.m., staff member A, maintenance director, stated an annual review had not been done on the bulk oxygen system.²

¹ NFPA 50 Standard for Bulk Oxygen Systems at Consumer Sites, 1996 Edition, Section 1-3 Definitions; For the purpose of the standard, the following terms are defined as follows: Bulk Oxygen System. A bulk oxygen system is an assembly of equipment, such as oxygen storage containers, pressure regulators, safety devices, vaporizers, manifolds, and interconnecting piping, that has a storage capacity of more than 20,000 ft3 (566 m3) of oxygen (NTP) including unconnected reserves on hand at the site. The bulk oxygen system terminates at the point where oxygen at service pressure first enters the supply line. The oxygen containers may be stationary or movable, and the oxygen may be stored as gas or liquid.

² NFPA 50, 1996 Edition, Section 4-2.1; Each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

Based on observation and interview, the facility failed to meet the medical gas storage requirements in accordance with NFPA 50, 1996 Edition, Sections 1-3 and 4-2.1. These deficiencies could affect 2 of 2 main floor smoke compartments.

Findings include:

During an observation on 9/29/15 at 11:15 a.m., the medical gas storeroom and area outside & adjacent to the storeroom was inspected. The amount of stored oxygen would qualify the area as a bulk oxygen system as it exceeded 20,000 cubic feet, on site.¹

During an interview on 9/29/15 at at 11:15 a.m., staff member A, maintenance director, stated an annual review had not been done on the bulk oxygen system.²

¹ NFPA 50 Standard for Bulk Oxygen Systems at Consumer Sites, 1996 Edition, Section 1-3 Definitions; For the purpose of the standard, the following terms are defined as follows: Bulk Oxygen System. A bulk oxygen system is an assembly of equipment, such as oxygen storage containers, pressure regulators, safety devices, vaporizers, manifolds, and interconnecting piping, that has a storage capacity of more than 20,000 ft3 (566 m3) of oxygen (NTP) including unconnected reserves on hand at the site. The bulk oxygen system terminates at the point where oxygen at service pressure first enters the supply line. The oxygen containers may be stationary or movable, and the oxygen may be stored as gas or liquid.

² NFPA 50, 1996 Edition, Section 4-2.1; Each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.