Improper Labeling of Medical Gas Cylinders
Penalty
Summary
The facility failed to maintain proper medical gas cylinder storage in the basement oxygen storage room, affecting one of two building levels. During an observation on January 23, 2025, it was noted that the storage room contained both full and empty cylinders that were not properly labeled to identify their gas levels. This lack of proper labeling could lead to confusion and improper handling of the gas cylinders. An interview with the maintenance supervisor on the same day confirmed the deficiency in medical gas cylinder storage. The supervisor acknowledged the issue, indicating that the facility did not adhere to the required standards for labeling and segregating full and empty cylinders. This oversight in maintaining the storage standards for medical gas cylinders was identified as a deficiency by the surveyors.
Plan Of Correction
Full and empty cylinders signage were labeled to identify gas levels in the basement oxygen storage room January 24, 2025. Education was provided to the Maintenance Director by the Administrator on January 24, 2025 regarding the requirement for full and empty cylinders signage to identify gas levels in the basement oxygen storage room. An audit will be conducted by the Maintenance Director to ensure that signage is in the basement oxygen storage room to identify full and empty oxygen cylinders. The audit will be conducted 4 times a week for 4 weeks, 3 times a week for 3 weeks, 2 times a week for 2 weeks then weekly ongoing. The audit will be monitored by the Administrator. Results of the audits will be presented at the quarterly QAPI meeting and recommendations.