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Based on observation, staff interview, and document review, it was determined that the facility failed to ensure transfilling of liquid oxygen is conducted in accordance with the National Fire Protections Association's Life Safety Code, 2012 edition and Health Care Facilities Code, 2012 edition.

Findings include:

Reference #1: 2012 edition of the National Fire Protection Association's Life Safety Code, "101:2.1 ... General. The Documents referred in this chapter, or portions of such documents, are referenced within this code, shall be considered part of the requirements of this code, and the following shall also apply: ... 2.2 NFPA Publications ... NFPA 99, Health Care Facilities Code, 2012 edition ..."

Reference #2: 2012 edition of the National Fire Protection Association's Life Safety Code, "101:19.3.2.4, Medical Gas. Medical gas storage and administration shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing."

Reference #3: National Fire Protection Association's Health Care Facilities Code, 2012 edition, "99:9.3.7.4 Transfilling area shall be provided with ventilation in accordance with NFPA 55, Compressed Gases and Cryogenic Fluids Code."

Reference #4: National Fire Protection Association's Compressed Gases and Cryogenic Fluids Code, 2010 edition, "55:8.13.1.3 Cryogenic Fluids. Cryogenic fluids in stationary or portable containers stored indoors shall be stored in buildings, rooms, or areas constructed in accordance with the building code."

Reference #5: National Fire Protection Association's Compressed Gases and Cryogenic Fluids Code, 2010 edition, "55:8.13.1.4 Ventilation. Ventilation shall be in accordance with Section 6.15."

Reference #6: National Fire Protection Association's Compressed Gases and Cryogenic Fluids Code, 2010 edition, "55:6.15 Ventilation. Indoor storage and use areas and storage buildings for compressed gasses and cryogenic fluids shall be provided with mechanical exhaust ventilation or natural ventilation ..."

Reference #7: National Fire Protection Association's Compressed Gases and Cryogenic Fluids Code, 2010 edition, "55:6.15.1 Mechanical Ventilation. Where mechanical ventilation is provided, the system shall be operational during the time the building is occupied."

Reference #8: National Fire Protection Association's Compressed Gases and Cryogenic Fluids Code, 2010 edition, "55:6.15.3 Mechanical Ventilation Rate. Mechanical ventilation shall be at a rate of not less than 1 cubic foot per minute per square foot of floor area over the area of storage or use."

Reference #9: National Fire Protection Association's Compressed Gases and Cryogenic Fluids Code, 2010 edition, "55:6.15.5 Shutoff Controls. Where powered ventilation is provided, a manual shutoff switch shall be provided outside the room in a position adjacent to the principal access door to the room or in an approved location."

Reference #10: National Fire Protection Association's Compressed Gases and Cryogenic Fluids Code, 2010 edition, "55.6.15.6 Manual Shutoff Switch. The switch shall be the break-glass or equivalent type and shall be labeled as follows: WARNING: VENTILATION SYSTEM EMERGENCY SHUTOFF"

Reference #11: National Fire Protection Association's Compressed Gases and Cryogenic Fluids Code, 2010 edition, "55:6.15.8 Floor level Exhaust. The location of both the exhaust and the inlet air openings shall be designed to provide air movement across all portions of the floor or room to prevent the accumulation of vapors."

Reference #12: Companion Liquid Oxygen Systems, Owners Manual B-701417-00 Rev.D, Page ii. "Be sure to read and understand this instruction manual completely before attempting to operate your Companion Liquid Oxygen system. Do not permit anyone who has not read and understand these instructions to handle or operate this equipment. ... Page 15, Caution, Clean and dry the fill connectors on both the Stationary and Portable units to prevent freezing and possible equipment failure. ...2. Using a clean dry, lint-free cloth, dry the male fill connector and female connector."

1. On January 9, 2018 at 12:00 PM, in the presence of Staff #2, two (2) 46 liters capacity Companion Liquid Oxygen Stationary Units, used for transfilling of liquid oxygen, where located in the Medical Gas Storage Room located adjacent to the Patient Shower Room.

a. During interview, Staff #2 and Staff #11 confirmed the following:

i. Liquid oxygen units are used for transfilling liquid oxygen into smaller portable liquid oxygen units carried by patients.

ii. Nursing Staff and Technicians perform the transfilling operation daily.

iii. Annual competencies do not contain information from the Manufacturer's instruction for use or from the Compressed Gas Association, as required by NFPA 99.

iv. Staff #11 stated, "I received training years ago when I first was hired. I train new staff myself recalling from memory what I remember from my initial training."

2. On January 9, 2018 at 12:15 PM, in the presence of Staff #2 and Staff #11, the Medical Gas Storage Room lacked the following:

a. Powered ventilation. Refer to Reference #6, Reference #7, Reference #8, Reference #9, and Reference #10.

b. A manual shutoff switch labeled and located outside the room. Refer to Reference #6, Reference #7, Reference #8, Reference #9, and Reference #10.

c. Exhaust and inlet air openings, designed to provide air movement across all portions of the floor and room to prevent the accumulation of vapors. Refer to Reference #11.

3. During interview, Staff #11 confirmed the following:

a. He/She had not read and understood the Companion Liquid Oxygen Systems, Owners Manual.

b. He/She does not use a clean dry, lint-free cloth to dry the male fill connector and female connector prior to transfilling.