Deficiencies in Oxygen Storage and Cylinder Identification
Penalty
Summary
The facility failed to maintain proper oxygen storage requirements, as evidenced by observations and interviews conducted during the survey. On the first level, the Clean Utility Room lacked the necessary precautionary signage for oxygen storage, which should include the wording: "CAUTION: OXIDIZING GAS(ES) STORED WITHIN, NO SMOKING." This deficiency was confirmed during an exit interview with the Maintenance Director. Additionally, the facility did not properly store and identify medical gas cylinders on one of the three floors. On the second floor, full and empty oxygen cylinders were mixed in both racks, and on the ground floor, the cylinders were not labeled to distinguish between full and empty. These issues were also confirmed during the exit interview with the Maintenance Director.
Plan Of Correction
Plan of Correction: Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. New signage was installed. First level clean utility room will be monitored weekly for 1 Quarter by a maintenance department designee to ensure this condition is not replicated. Preparation and submission of this POC is required by State and Federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceedings. K 0923 a & b A. New signage will be installed on second floor inside oxygen storage to ensure there is no mixing of full versus empty cylinders. Area will be monitored weekly for 1 quarter by a maintenance department designee to ensure this condition is not replicated. B. New signage on ground floor will be installed to label/designate full versus empty cylinders. Area will be monitored weekly for 1 quarter by a maintenance department designee to ensure this condition is not replicated.