Improper Storage of ABHR Exceeding Allowable Limits
Penalty
Summary
The facility failed to ensure proper storage of Alcohol Based Hand Rub (ABHR) dispensers, exceeding the allowable limit of five gallons in a single smoke compartment. This deficiency was observed in one of the three buildings, specifically in the Atrium Building #1, Resident room #308. During the survey, it was noted that there were 61 cases, each containing six one-liter containers of ABHR, amounting to approximately 96 gallons. The label on each dispenser indicated that the active ingredient was 80% ethyl alcohol, and it included warnings about flammability and the need to keep the product away from fire or flame. The survey conducted on December 17, 2024, revealed that the facility did not comply with the requirements for storing ABHR, as outlined in the NFPA 101 and related regulations. The dispensers were not stored in a proper location, which is a violation of the safety standards. This issue was brought to the attention of the facility's representatives during the Life Safety survey exit on December 18, 2024.
Plan Of Correction
1. No residents experienced negative outcomes as a result of the deficient practice of excess storage of alcohol-based hand rub sanitizer within a single smoke compartment. On 12/18/2024, the excess supply was immediately discarded appropriately. 2. All residents have the potential to be affected by this deficient practice. Additional supply closets were audited and no issues were found. 3. On 12/18/2024, Maintenance and Housekeeping staff were educated by the regional Plant Operations Director on proper storage of Alcohol-based hand rub sanitizer. 4. Maintenance Director/Designee will audit single smoke compartments for alcohol-based hand rub sanitizer storage monthly for x3 months. Any concerning findings will be corrected immediately. The results of these audits will be reported to the monthly Quality Assurance Performance Improvement committee.