Oxygen Storage Signage Deficiency
Penalty
Summary
The facility failed to maintain proper oxygen storage requirements on one of its six floors. During an observation on January 29, 2025, at 9:07 a.m., it was noted that the Clean Utility Room on the first floor lacked the necessary signage to distinguish between 'empty' and 'full' oxygen cylinders. This deficiency was identified as a failure to comply with the National Fire Protection Association (NFPA) standards for gas equipment storage, which require clear labeling to prevent confusion and ensure safety. The absence of appropriate signage was confirmed during an exit interview with the Facility Administrator and Maintenance Director later that morning. This oversight in maintaining the required oxygen storage protocols could potentially lead to mishandling of oxygen cylinders, although the report does not specify any direct consequences or risks resulting from this deficiency.
Plan Of Correction
Empty and Full Oxygen cylinder signage was hung in the clean utility room identified. Maintenance staff was educated on the importance of Oxygen cylinder signage. Maintenance director/designee will conduct monthly audits x 3 months to ensure all Oxygen storage areas have necessary signage. Audits will be reviewed/reported to QAPI Committee. QAPI Committee will determine the need for continued audits.