There were full and non-full e-cylinders of oxygen co-mingled on a rack located on the loading dock.
Gloria’s clarification read:
The report of survey findings cited that at the xxx location, “there were full and non-full e-cylinders of oxygen co-mingled on a rack located on the loading dock”.
NFPA 99-1999 section 4-220.127.116.11(b), which parallels the accreditation organization standard, requires that gas cylinders should be stored in such a way that staff retrieving them in a hurry will not have to make a decision about which cylinders are full and which are not. The accreditation organization published an article that cautioned hospitals to make sure full and partial or empty cylinders are physically separated to prevent staff confusion when retrieving a cylinder during an emergency.
The Hospital’s policy on storage of medical gas cylinders follows the requirements set forth by the NFPA and the accreditation organization for the storage of medical gas cylinders, however, the requirements of both the NFPA and the wording from the accreditor’s article cited, stress that the delineated storage requirements are to “prevent staff confusion when retrieving a cylinder during an emergency”.
The findings cited from our triennial survey indicate “full and non-full e-cylinders of oxygen co-mingled on a rack located on the loading dock”. The cylinders located on the loading dock are not ‘in storage’ for patient use. The cylinders, located on the loading dock area, are in a state of flux of shipping and receiving; either being delivered or retrieved by the delivery company or are overflow of product that exceeds the storage capabilities within the hospital. The cylinders are not accessible by staff caring for patients and patient care is never delivered in this area. Once the cylinders are brought into the hospital for use, the cylinders are appropriately stored in the designated racks in the patient care areas which differentiate by both location and signage separating the full cylinders from in-use/empty cylinders so that there would never be confusion by staff when retrieving oxygen cylinders for use in emergency situations or daily need.
The reply from the accreditor:
The clarifying evidence was accepted for observation 1 based on the cylinders being located on the loading dock and not interior to the building
So the lesson learned here is to know and understand the codes and standards you are being surveyed against. Surveyors try and do the best job that they can, but they are not the final authority on the interpretation of the standards. It would have been interesting to know what the surveyor would have done if the above documentation was presented during the survey. Would the surveyor accepted the issue on the spot or would the surveyor have continued to document the finding?