Deficiency in Securing Oxygen Cylinders and Electrical Safety
Penalty
Summary
The facility was found to have deficiencies related to the handling and securing of portable oxygen cylinders. During an observation on April 8, 2025, between 10:50 AM and 11:27 AM, it was noted that portable oxygen cylinders were unsecured in various locations across the facility. Specifically, one cylinder was found unsecured in the 4th floor Therapy Room, two cylinders in the 4th floor Medicine Room, one cylinder in the 3rd floor Medicine Room, two cylinders in the 2nd floor Director of Nursing Office, and one cylinder in the 2nd floor Medicine Room. An interview with the Maintenance Director confirmed that these cylinders were not secured, which is a violation of the NFPA 99 standards for handling oxygen equipment. Additionally, a receptacle multiplier was observed supplying power to a radio and a camera by the Lobby fireplace, which was also confirmed by the Maintenance Director.
Plan Of Correction
1. The oxygen cylinders that were unsecured were secured and placed appropriately in racks on 04-08-2025. 2. Maintenance Director and Director of Nursing, or designees, will educate maintenance and nursing staff on properly securing oxygen cylinders. Maintenance Director will audit weekly for two weeks, then monthly to ensure that oxygen cylinders are properly secured in racks. Results of audits will be submitted to monthly QAPI for review and recommendations.