Unsecured Oxygen Cylinder in Dialysis Room
Penalty
Summary
The facility failed to maintain gas equipment-cylinder and container storage in accordance with NFPA 101 standards. During a Life Safety Survey tour conducted between 11:00 am and 4:30 pm on April 8, 2025, an unsecured oxygen cylinder was observed in the Dialysis Room. This cylinder was in use by a resident at the time of the survey. The unsecured state of the cylinder was noted as a deficiency in the facility's adherence to safety regulations. The survey was conducted with the Maintenance Director, who acknowledged the finding during the tour. The unsecured oxygen cylinder was identified at 2:06 pm, highlighting a lapse in the facility's protocol for securing gas equipment. The observation was made in the presence of the Maintenance Director, ensuring that the deficiency was recognized by the facility's staff. The deficiency was further discussed and acknowledged by the Administrator during the exit conference. The report cites specific sections of the NFPA 101 and NFPA 99 standards that were not met, emphasizing the importance of proper storage and handling of gas equipment to ensure safety within the facility. The failure to secure the oxygen cylinder represents a breach in compliance with these safety standards.
Plan Of Correction
Responsible Party: The Director of Maintenance Immediate Action: Oxygen cylinder was secured upon identification. A facility wide audit was conducted to identify unsecured cylinder holders. Identification of Residents with potential to be affected: All in-house residents have potential to be affected. System Changes: All oxygen cylinder holders without a safety mechanism were removed from circulation. The safety mechanism was installed on those holders. Education for oxygen cylinder safety training was conducted with licensed staff. Upon identification of unsure holder, they must remove the holder from circulation and report to the Maintenance Department via Worx hub. Monitoring: Daily audits of all oxygen cylinder holders in storage areas to ensure all oxygen cylinder holders are secure prior to use. Results of the daily audit will be reported to Monthly Quality Assurance Performance Improvement Committee meeting for the next 90 days or until the committee agrees substantial compliance is met. Responsible Party: Director of Maintenance or designee