HospitalInspections.org

National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 1999 Edition
Chapter 8 Gas Equipment
8-3.1.11 Storage Requirements.
8-3.1.11.2
Storage for nonflammable gases less than 3000 ft3 (85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
d) Liquefied gas container storage shall comply with 4-3.1.1.2(b)4.
(e) Cylinder and container storage locations shall meet 4-3.1.1.2(a)11e with respect to temperature limitations.
(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.
(g) Cylinder protection from mechanical shock shall meet 4-3.5.2.1(b)13.
(h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.
(i) Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20 ft (6.1 m) of outside storage locations.
(j) Cylinder valve protection caps shall meet 4-3.5.2.1(b)14.
8-3.1.11.3 Signs.
A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

This Standard is not met as evidenced by:

Based on observation it was determined the facility failed to store all oxygen cylinders in accordance with National Fire Protection Association (NFPA) 99.

Findings include:

1. During a tour of the hospital outside area on 11/06/12 at approximately 1:35 p.m., the oxygen storage building located at the loading dock was not identified with the proper sign. At this time several small cylinders were observed not secured by chain.

2. These findings were discussed with the hospital maintenance staff on 11/06/12 at approximately 1:40 p.m. and agreed that the oxygen storage area was not maintained in accordance with NFPA 99.

National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 1999 edition
Chapter 3 Electrical Systems
3-4 Essential Electrical Systems Requirements - Type I
3-4.2.2.2 Emergency System.
(a) General. Those functions of patient care depending on lighting or appliances that are permitted to be connected to the emergency system are divided into two mandatory branches, described in 3-4.2.2.2(b) and (c).
+All ac-powered support and accessory equipment necessary to the operation of the EPS shall be supplied from the load side of the automatic transfer switch(es), or the output terminals of the EPS, ahead of the main EPS overcurrent protection, as necessary, to ensure continuity of the EPSS operation and performance. (NFPA 110: 5-12.5)
(b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,® Life Safety Code®
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, " Gas and Vacuum Systems "
4. * Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.

NFPA 110 Standard for Emergency and Standby Power Systems 1999 Edition
Chapter 5 Installation and Environmental Considerations
5-3 Lighting.
5-3.1
The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

This Standard is not met as evidenced by:

Based on observation and staff interview, it was determined the hospital failed to maintain the emergency generator and transfer switch in accordance with National Fire Protection Association (NFPA) 99 and 110.

Findings include:

1. During an inspection of the hospital emergency generators and transfer switch for the fire pump on 11/06/12 at approximately 2:00 p.m., the required battery emergency illumination light was not provided at the transfer switch.

2. These findings were discussed with the hospital maintenance staff on 11/06/12 at approximately 2:15 p.m. and agreed there was no battery lighting for the fire pump transfer switch.