Improper Storage and Identification of Medical Gas Cylinders
Penalty
Summary
Surveyors observed that the facility failed to properly store and identify medical gas cylinders across all four floors. Specifically, on the fourth, third, and second floors, oxygen closets adjacent to rooms 4815, 3815, and 2815 each contained more than 12 tanks, with the third floor also having 2 freestanding cylinders. On the first floor, the oxygen closet in the service corridor contained approximately 50 stored cylinders and 15 freestanding cylinders. These storage practices did not comply with NFPA 101 and NFPA 99 requirements for gas cylinder storage, including limitations on the number of cylinders, proper enclosure, and segregation of full and empty cylinders. The improper storage was confirmed during an exit interview with the Maintenance Supervisor and Director of Safety/Security. The report does not mention any specific residents or patient conditions related to the deficiency, nor does it describe any immediate consequences resulting from the improper storage. The deficiency was based solely on the observed storage conditions and the facility's failure to meet regulatory standards for medical gas cylinder management.
Plan Of Correction
Oxygen storage capacity will be limited to 12 full tanks on the 2nd, 3rd, and 4th floors, and 50 full tanks on the 1st floor. Staff educated on storage capacity and that all tanks must be placed in holders and not free-standing. Nurses will audit at the beginning of each shift, and supervisors will perform random audits to monitor compliance.