HospitalInspections.org

Based on observation and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by: 1) full and empty portable oxygen cylinders not separated and the storage area did not have signs to identify the full and empty cylinders; and 2) the hospital did not have a functioning piped medical gas and vacuum system to service all of the medical needs of the patients.

Findings:
Review of hospital policy III-B.2.21, Medical Gas Safe Storage, reviewed 4/2020 revealed in part, "5. Empty cylinders may be stored in the same room as the full tanks but must be in a separate bracket/cart and designated as being empty by a secured laminated sign.

A review of the Life Safety Codes revealed in part:
NFPA 99:11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders.
NFPA 99:11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner.

NFPA 99:5.1 Category 1 Piped Gas and Vacuum Systems.

NFPA 99:5.1.1* Applicability.

NFPA 99:5.1.1.1 These requirements shall apply to health care facilities that require Category 1 systems as referenced in Chapter 4.

NFPA 99:4.1.1* Category 1. Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers shall be designed to meet system Category 1 requirements as defined in this code.

1) Full and empty portable oxygen cylinders were not separated and the storage area did not have signs to identify the full and empty cylinders.

Tour of the facility on 05/02/2022 at 8: 27 a.m. revealed the empty portable oxygen canisters were in the same rack with the two full oxygen cylinders. There were no signs to indicate where the full and empty canisters were to be stored.

During the tour of the facility at 8:27 a.m., S5M verified the full canisters were stored with the empty canisters and the storage did not have signs to indicate where the full and empty canisters should be stored.

2) The hospital lacked a functioning piped medical gas and vacuum system to service all of the medical needs of the patients.

During the facility tour on 05/02/2022 between 8:10 a.m. and 8:30 a.m., the facility was noted to have a piped medical gas and vacuum system but it was not working.

In interview on 05/02/2022 at 8:40 a.m., S1CCO and S2Adm verified that the piped gas system was not functional. S1CCO and S2Adm also verified the offsite location did not have a piped medical gas system either.