Unsecured Oxygen Cylinder Found in Storage Room
Penalty
Summary
The facility failed to maintain medical gas storage requirements, as evidenced by an unsecured oxygen cylinder found in the Oxygen Storage Room on the first floor of Countryside. This observation was made during a survey on January 8, 2025, at 9:50 a.m. The deficiency was noted in one of the four smoke compartments, indicating a lapse in adherence to the National Fire Protection Association (NFPA) standards for gas equipment storage. During an interview conducted on the same day at 1:30 p.m., the Facility Administrator and Maintenance Director confirmed the deficiency related to medical gas storage. The unsecured cylinder represents a failure to comply with the NFPA 99 requirements, which mandate that storage locations for medical gases be designed, constructed, and ventilated according to specific guidelines to ensure safety and compliance.
Plan Of Correction
The improperly stored oxygen cylinder was chained on the date of discovery to ensure compliance. All rooms in the building where oxygen is located will be audited for proper storage of oxygen cylinders. The nursing and maintenance team will be reeducated before the compliance date about the storage of oxygen in the oxygen storage locations. The oxygen rooms will be audited weekly for four weeks and monthly for three months to ensure oxygen cylinders are stored properly. The audits will be presented at the quarterly QAPI committee for review of any negative trends that may require performance improvement plans.