Improper Storage of Alcohol-Based Hand Rub in Administration Area
Penalty
Summary
During a Life Safety Code survey, it was observed that alcohol-based hand rub (ABHR) was improperly stored in the Administration area on the Second Floor of the facility. Specifically, nine one-gallon containers of liquid hand sanitizer, each containing 80% Ethyl Alcohol, were stored in a storage closet across from Storage room 216. This storage exceeded the allowable quantity of five gallons in a single smoke compartment and did not meet the requirements of the 2012 edition of the National Fire Protection Association (NFPA) 30: Flammable and Combustible Liquids Code. Further observations revealed that the door to the storage closet did not self-close and latch into its door frame, nor was it equipped with a self-closing device, which is necessary for areas storing flammable materials. During an interview, the Maintenance Director admitted to being unaware of the storage of these containers in the closet and acknowledged the regulations regarding the storage of alcohol-based hand sanitizer. This oversight affected the safety protocols required for hazardous areas, as outlined in the facility's policy and procedure for alcohol-based hand sanitizers.
Plan Of Correction
Plan of Correction: Approved January 2, 2025 1. 2nd Floor Administration Area - The door to the storage closet was repaired by Maintenance Director with a self-closing device. All liquid hand sanitizer was removed to a more appropriate storage area by Maintenance Director with proper signage. 2. All residents are at risk for deficient practice of liquids in quantities greater than 5 gallons in a single smoke compartment not being stored in proper hazardous areas. 3. A full facility audit of all storage areas will be conducted by the Director of Maintenance to ensure that liquid alcohol-based hand rub or other flammable items were properly stored and proper signage was in place. 4. The policy "Alcohol-Based Hand Sanitizer and Solutions" with a date of revision of 12/24, was reviewed by the Consultant; no revision was necessary. 5. All facility staff will be in-serviced on proper storage of liquid alcohol-based hand rub and other flammable liquids by the Consultant, (NAME) J Pietrowski, MSN RN LNHA. 6. A weekly audit will be completed by Maintenance Director/Tech to ensure alcohol-based hand rub and other flammable liquids are stored properly. Any deficient practice will be corrected and brought to QAPI for further review. Person Responsible: Maintenance Director