Unsecured Oxygen Cylinder in Transport Cart
Penalty
Summary
The facility failed to manage an oxygen cylinder in accordance with NFPA 99 standards. During a facility tour conducted by the Maintenance Director and the Regional Maintenance Consultant, it was observed that an e-size oxygen cylinder in a transport cart was unsecured. The cylinder was not properly secured to the cart, which is a violation of the safety standards outlined in NFPA 99. The observations were confirmed through an interview with the Maintenance Director and the Regional Maintenance Consultant, who acknowledged the findings. These findings were subsequently reviewed with the Administrator, the Maintenance Director, and the Regional Maintenance Consultant during the exit conference. Photographic evidence was obtained to document the unsecured oxygen cylinder, further substantiating the deficiency.
Plan Of Correction
1. The e-size oxygen cylinder in transport cart was secured on 03/31/2025 by the Maintenance Director. 2. The Maintenance Director conducted quality assurance check on e-size oxygen cylinders in transport carts to ensure they were secured on 4/1/2025 and no additional findings notes. 3. Education was provided to facility staff on securing e-size oxygen cylinder in transport securely by the NHA or designee by 4/25/2025. The Maintenance Director, or designee, will conduct weekly for 12 weeks audit on 5 random e-size oxygen cylinders in transport carts to ensure they are secured. 4. All results of the quality assurance checks will be monitored and reviewed by the QA&A committee monthly until substantial compliance is assured.