Improper Storage of Medical Gas Cylinders
Penalty
Summary
The facility failed to maintain proper storage for medical gas cylinders, as observed during a tour conducted on March 3, 2025. The deficiency was identified in the 1st floor clean utility and soiled utility rooms, where medical gas is stored. The doors to these rooms, which open to the corridor, were found to be unable to close, latch, and lock, thereby failing to ensure unauthorized entry prevention. This issue was confirmed through an interview with the RMS conducted concurrently with the observations. The report highlights the importance of proper storage and handling of compressed gases for the safety of staff, patients, and visitors within the facility. The facility's failure to comply with NFPA 99 and NFPA 101 standards, specifically regarding the security and proper enclosure of medical gas storage areas, constitutes a significant safety concern. The deficiency was documented based on the observations and interviews conducted during the facility tour.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 3/3/25, 1st floor clean utility and soiled utility room doors were immediately assessed for parts to fix the unlatched doors. No negative outcome identified. On 3/3/25, 1st floor clean utility and soiled utility keypads were immediately ordered for doors. No negative outcome identified. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken? On 3/3/25, an assessment of all rooms where stored oxygen cylinders were inspected. No additional areas of concern were found to be affected by the alleged deficient practice. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On 3/7/25, 1st floor clean utility and soiled utility room doors were corrected with new lock and latch to ensure proper closure. On 3/7/25, 1st floor clean utility and soiled utility room door keypads were added to ensure authorized entry. On 3/4/25, maintenance staff was educated on the components of K923 Gas Equipment, Cylinder and Container Storage with an emphasis to maintain proper storage for medical gas cylinders by the Administrator/Designee. Any newly hired Maintenance Director will be educated on maintaining proper storage for medical gas cylinders by the Administrator/Designee on the components of K923 Gas Equipment, Cylinder and Container Storage. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Administrator/designee to conduct door and storage audits 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure proper storage for medical gas cylinders. The findings of these quality monitoring audits to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met. 3/11/25 (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 3/3/25, 1st floor clean utility and soiled utility room doors were immediately assessed for parts to fix the unlatched doors. No negative outcome identified. On 3/3/25, 1st floor clean utility and soiled utility keypads were immediately ordered for doors. No negative outcome identified. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken? On 3/3/25, an assessment of all rooms where stored oxygen cylinders were inspected. No additional areas of concern were found to be affected by the alleged deficient practice. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur,