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Based on visual observation the facility failed to properly place the portable medical gas cylinders in the correct orientation by separating the medical gas cylinders into groups of full and empty. When medical gas cylinders are not properly stored the risk of a fire/smoke emergency increases. The deficiency has the potential to affect seven of seven patients.

Findings:

During the facility tour on March 29, 2022 between the hours of 9:30 a.m. to 3:30 p.m. it was observed the full and the empty portable oxygen cylinders were not separated. There were two of the portable oxygen cylinders that were free standing without a chain or a rack to secure the cylinders in the upright position.


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 99:11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures:
(1) Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device.
(2) Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them.
(3) Cylinders shall be protected from tampering by unauthorized individuals.
(4) Cylinders or cylinder valves shall not be repaired, painted, or altered.
(5) Safety relief devices in valves or cylinders shall not be tampered with.
(6) Valve outlets clogged with ice shall be thawed with warm - not boiling - water.
(7) A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device.
(8) Sparks and flame shall be kept away from cylinders.
(9) Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them.
(10) Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1.
(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
(12) Cylinders shall not be supported by radiators, steam pipes, or heat ducts.
The interview with the Assistant Administrator revealed the facility was aware the portable oxygen cylinders were located in a oxygen room adjacent to the main nursing station and all oxygen portable cylinders were required to have the oxygen full tanks separated from the oxygen empty cylinders. The Assistant Administrator was also aware that all of the portable oxygen cylinders were required to be secured in the upright position at all times.

Based on visual observation, the acute care Hospital facility failed to provide a medical gas central supply system for patients who were likely to have major injury or death from a severe medical condition. A properly maintained medical central supply gas and vacuum system provide essential utility and provide critical sources for life supporting gases that are required for proper treatment of patients in the health care environment. This deficiency could potentially affect seven of seven patients.

Findings:

During the facility tour on March 29, 2022 between the hours of 9:30 a.m. to 3:30 p.m. this licensed Long Term Acute Care Hospital facility lacked medical gas piping and a vacuum system to service all of the medical needs of the patients.

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.

LRS 40:1574.1

B.(1) In order to comply with the requirements of R.S. 40:1574, only one set of plans shall be submitted to the state fire marshal for review.

(2) When the plans are reviewed by the office of state fire marshal, code enforcement and building safety, the original set of plans properly stamped "Reviewed" by the state fire marshal shall be retained by the contractor for the construction, renovation, or remodeling for the project in question as long as the structure, watercraft, or movable is in the process of construction, renovation, or remodeling.

(3) Upon final completion of the project the contractor shall turn the plans over to the owner.

(4)(a) The state fire marshal shall furnish to the parties submitting the plans which appear to him to satisfactorily comply with the laws, rules, regulations, and codes of the state and the regulations of the state fire marshal the original set of plans, blueprints, or both stamped reviewed along with a letter which shall state that the plans appear to him to satisfactorily comply with the laws, rules, regulations, and codes of the state and the regulations of the fire marshal.

(b) This letter from the fire marshal stating that the plans and specifications for the construction, renovation, or remodeling for the project in question appear to satisfactorily comply with the laws, rules, regulations, and codes of the state, in no way permits and authorizes any omission or deviation from those laws, rules, regulations, and codes so that in no way does this review procedure permit, authorize, or otherwise increase or incur any liability by the state for failure to recognize and point out any such omission or deviation in those requirements.

(c) The letter and reviewed plans of the fire marshal shall be kept at the site of the project for inspection by the fire marshal or his deputies for as long as the structure, watercraft, or movable is in the process of construction, renovation, or remodeling.

(5) The office of state fire marshal, code enforcement and building safety shall no longer retain any copy of the reviewed plans or blueprints and is hereby authorized to destroy all such plans and blueprints currently in the archives of the state fire marshal after one year has passed from the effective date of this Section.

(6) The owners of all structures, watercraft, and movables shall retain blueprints including the original building plans and specifications which have been stamped "Reviewed" by the state fire marshal in a safe place for as long as the structure, watercraft, or movable is occupied, used, or both.

C.(1) In the event that plans do not appear to the fire marshal to satisfactorily comply with the laws, regulations, and codes of Louisiana and the regulations of the state fire marshal, the state fire marshal shall furnish a letter to the party submitting the plans which shall list the particular requirements of the state fire marshal which must be met before the plans can be stamped "Reviewed" and before construction or renovation or remodeling can begin. However, where plans for projects are submitted in violation of R.S. 37:155(A)(4), no list of requirements shall be provided.

(2) Review of the plans submitted constitutes compliance with this Section if construction begins within one hundred eighty days of the review.

(3) State and local political subdivisions shall be exempt from the payment of all other charges provided herein, for the first submission only. Thereafter, for all subsequent submissions, state and local political subdivisions shall pay the required fees.

D. All fees collected pursuant to Subsection A of this Section shall be used exclusively for the maintenance and operation of the planning review section of the office of the state fire marshal, code enforcement and building safety.

The interview with the Assistant Administrator revealed the facility was not aware the licensed Long Term Acute Care classification requires medical gas piping and a vacuum system to provide critical life supporting treatment for all patients.