Improper Storage of Medical Gas Cylinders
Penalty
Summary
The facility failed to properly store and identify medical gas cylinders, specifically oxygen cylinders, on the fifth floor. During an observation on February 13, 2025, it was noted that the portable oxygen storage room contained a mix of full and empty cylinders in both the full and empty racks. This improper storage practice was identified as a deficiency in the facility's compliance with NFPA 101 standards for gas equipment storage. The deficiency was confirmed during an interview at the exit conference with the Chief Operating Officer, Administrator, and Maintenance Director. The report highlights that the facility did not adhere to the required protocols for segregating full and empty cylinders, which is essential for maintaining safety and compliance with regulatory standards.
Plan Of Correction
1. No Residents were affected by this practice. 2. All other O2 storage was in compliance. 3. Back O2 Storage will now be labeled and store only Full tanks. Front O2 storage room will now be labeled and store only Empty tanks. Staff will be in-serviced on the new practice by 3/8/25. 4. Lead RT will audit for compliance weekly and will bring results of audits to monthly Safety & QAPI meetings overseen by the Administrator.