Failure to Segregate Full and Empty Oxygen Cylinders
Penalty
Summary
During an observation and interview conducted near a resident room, surveyors found that the facility failed to segregate full oxygen cylinders from empty ones in one of three smoke compartments. Specifically, three empty oxygen cylinders were stored together with full oxygen cylinders in the oxygen storage closet. This was confirmed during the interview with facility staff present at the time of the observation. The report notes that the Respiratory Manager/Designee acknowledged the need for separation of full and empty cylinders. The failure to properly segregate the cylinders was identified as a deficient practice, as it could potentially confuse staff regarding which cylinders are full and which are empty during an emergency.
Plan Of Correction
Correct Deficient Practice: On 3/07/25 Central Supply separated and arranged the oxygen tanks accordingly. Identify Others: All residents, employees, and visitors are at risk due to this deficient practice. Systemic Changes: On 03/10/2025, Administrator provided in-service education to Maintenance Supervisor and Central Supply regarding the proper storage of oxygen tanks. Admin to check oxygen storage room weekly. Any negative findings will be reported to administrator and corrected immediately. Monitoring: Findings and trends from inspection rounds will be brought to the Quarterly Safety Committee meeting by MS until the Safety Committee has determined compliance has been sustained. Facility's Safety Committee will provide further recommendations as necessary. Completion Date: 3/28/2025. Christian Urbina, NHA Administrator