Deficiency in Oxygen Cylinder Handling Training
Penalty
Summary
The facility failed to manage pressurized oxygen cylinders in accordance with the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 Edition section 11.5.2.1. Specifically, 19 out of 63 employees who handle oxygen cylinders did not receive the required education on the risks associated with their handling and use. This deficiency was identified through record review and interviews during a recertification survey. It was noted that there was no documented evidence of periodic training for these employees, including those working in the physical therapy department and the medical treatment section. A registered nurse confirmed that staff in these areas had not received the necessary training on the risks and proper handling of oxygen cylinders.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. There were nineteen (19) staff identified as not having completed annual Compressed Gas Education. B. Any staff member who was identified as incomplete including staff in [MEDICAL TREATMENT] and Physical Therapy will complete the annual Compressed Gas Training prior to 3/04/2025. C. Any staff who did not complete the Compressed Gas Training by 03/04/2025 will be removed from the schedule and unable to work on the Skilled Nursing Unit until verification of completion. 2. All residents of the Skilled Nursing Facility have the potential to be affected by this alleged deficient practice. 3. The Organizational Development Coordinator will provide an Education report for completion status of the Compressed Gas Training. This will be reviewed monthly to ensure all staff of the Skilled Nursing Facility are compliant with Compressed Gas Training. Education will be documented in the facility electronic education software or on the education sign-in sheet. Staff who are not compliant will be removed from the schedule until verification of completion. All other staff working in the Skilled Nursing Facility will be reviewed for the required training, and those that have not will receive the training. 4. Completion Report of the Compressed Gas will be audited monthly, with audit results reviewed at the Monthly Quality Assurance Performance Improvement Committee for recommendations. Responsible Party - Director of Nursing / Designee