Current through Reg. 49, No. 52; December 27, 2024
(a) Flammable
germicides. If flammable germicides, including alcohol-based products, are used
for preoperative surgical skin preparation in a limited services rural hospital
(LSRH), the LSRH must:
(1) use only
self-contained, single-use, pre-measured applicators to apply the surgical skin
preparations;
(2) follow all
manufacturer product safety warnings and guidelines;
(3) develop, implement, and enforce written
policies and procedures outlining the safety precautions required related to
the use of the products, which, at a minimum, must include minimum drying
times, prevention and management of product pooling, parameters related to
draping and the use of ignition sources, staff responsibilities related to
ensuring safe use of the product, and documentation requirements sufficient to
evaluate compliance with the written policies and procedures;
(4) ensure that all staff working in the
surgical environment where flammable surgical skin preparation products are in
use have received training on product safety and the facility policies and
procedures related to the use of the product;
(5) develop, implement, and enforce an
interdisciplinary team process for the investigation and analysis of all
surgical suite fires and alleged violations of the policies; and
(6) report all occurrences of surgical suite
fires to the Texas Health and Human Services Commission as soon as possible but
not later than 10 calendar days after the occurrence, and complete an
investigation of the occurrence and develop and implement a corrective action
plan within 30 days after a surgical suite fire.
(b) Flammable and nonflammable gases and
liquids. Flammability of liquids and gases shall be determined by National Fire
Protection Association (NFPA) 329, Recommended Practice for Handling Releases
of Flammable and Combustible Liquids and Gases, 2010 edition.
(1) Nonflammable gases (examples including
oxygen and nitrous oxide) shall be stored and distributed in accordance with
Chapter 5 of the NFPA 99, Standard for Health Care Facilities, 2012 edition.
(A) Medical gases and liquefied medical gases
shall be handled in accordance with the requirements of NFPA 99 Chapter
9.
(B) Oxygen shall be administered
in accordance with NFPA 99 §9.6.
(2) Piped flammable gas systems intended for
use in laboratories and piping systems for fuel gases shall comply with
requirements of NFPA 99 §11.11.
(3) Flammable gases shall be stored in
accordance with NFPA 99 §11.10.
(4) Flammable and combustible liquids used in
laboratories shall be handled and stored in accordance with NFPA 99 §11.7,
and National Fire Protection Association 101, Life Safety Code, 2012 edition,
§18.3.2.2.
(5) Other flammable
agents shall be stored in accordance with NFPA 99 Chapter 7.
(c) Gasoline and gasoline powered
equipment. No motor vehicles including gasoline powered standby generators or
any amount of gasoline shall be located within the LSRH building. Other devices
that may cause or communicate fire, and that are not necessary for patient
treatment or care, shall not be stored within the LSRH building. All such
devices and materials when necessary shall be used within the building only
with precautions ensuring a reasonable degree of safety from fire.
(d) Gas-fired appliances. The installation,
use, and maintenance of gas-fired appliances and gas piping installations shall
comply with the National Fire Protection Association 54, National Fuel Gas
Code, 2012 edition. The use of portable gas heaters and unvented open flame
heaters is specifically prohibited.
