Improper Storage of Portable Oxygen Cylinder
Penalty
Summary
A deficiency was identified when a portable oxygen tank was observed freestanding and not properly secured in Bedroom 18. This observation was made during a facility tour and interview with the Administrator and Maintenance Director. The oxygen tank was not chained or supported in a proper cylinder stand or cart, as required by NFPA 99, Health Care Facilities Code, 2012 Edition, section 11.6.2.3. The Maintenance Director stated that a nurse was likely replacing the oxygen tank and left the old one in the room. This incident affected two of 93 residents in one of four smoke compartments. The report specifically notes that the portable oxygen tank was not properly secured, which is a violation of the regulations for gas equipment cylinder and container storage. No additional details about the residents' medical history or condition at the time of the deficiency are provided in the report.
Plan Of Correction
K923 • How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Oxygen tank was removed from room 18 on 6/25/25 and replaced with an oxygen tank that was fully secured. • How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: DON and DSD audited all rooms within the facility and found no other freestanding oxygen tanks, no other residents were affected. • What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: Administrator gave 1:1 inservice with Central supply coordinator (CSC) on 6/26/25. CSC will be auditing all rooms 2 x week to verify all oxygen tanks are properly stored in resident rooms and oxygen storage rooms. • How the facility plans to monitor its performance to make sure that solutions are sustained: Central supply coordinator will bring audit findings to monthly QA meeting until 3 consecutive months with no findings. • Include dates when corrective action will be completed: Completed 6/26/25