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The facility did not ensure that storage and transferring of oxygen was in compliance with the requirements of NFPA 99 " Health Care Facilities " .

a. On 06/28/10 at 11:45 AM, the surveyor along with the Physical Plant Director observed that the Respiratory Therapy Department was storing one (1) 41 liter and one (1) 31 liter liquid oxygen reservoir in a storage room within Room 1434 which contained combustible tubing, papers, and supplies;

b. On 06/28/10 at 11:45 AM, the surveyor along with the Physical Plant Director, observed that the Respiratory Therapy Department was utilizing one (1) 41 liter and one (1) 31 liter liquid oxygen reservoir to transfill liquid oxygen to liquid companion portables in a storage room within Room 1434 that was not in compliance with NFPA 99 " Health Care Facilities ", i.e. the room was not one-hour fire rated; the door lacked a self-closing device; the room contained VCT flooring instead of ceramic tile or concrete; the room lacked continuous dedicated mechanical ventilation to the exterior, and the room was not separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction. Upon surveyor request, an immediate action plan was developed by hospital administration and facilities staff to move the oxygen to an area compliant with regulations and staff were educated regarding requirements related to the transfilling of oxygen.

The facility did not ensure that storage and transferring of oxygen was in compliance with the requirements of NFPA 99 " Health Care Facilities " .

a. On 06/28/10 at 11:45 AM, the surveyor along with the Physical Plant Director observed that the Respiratory Therapy Department was storing one (1) 41 liter and one (1) 31 liter liquid oxygen reservoir in a storage room within Room 1434 which contained combustible tubing, papers, and supplies;

b. On 06/28/10 at 11:45 AM, the surveyor along with the Physical Plant Director, observed that the Respiratory Therapy Department was utilizing one (1) 41 liter and one (1) 31 liter liquid oxygen reservoir to transfill liquid oxygen to liquid companion portables in a storage room within Room 1434 that was not in compliance with NFPA 99 " Health Care Facilities ", i.e. the room was not one-hour fire rated; the door lacked a self-closing device; the room contained VCT flooring instead of ceramic tile or concrete; the room lacked continuous dedicated mechanical ventilation to the exterior, and the room was not separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction. Upon surveyor request, an immediate action plan was developed by hospital administration and facilities staff to move the oxygen to an area compliant with regulations and staff were educated regarding requirements related to the transfilling of oxygen.