Improper Storage of Oxygen Cylinders
Summary
During a Life Safety Code survey, deficiencies were identified in the storage and maintenance of oxygen cylinders in a long-term care facility. On Unit 1/2, two E-sized oxygen cylinders were found stored in a Clean Utility room, only four inches away from combustible materials such as cardboard boxes containing disposable gowns and face shields. The room's door was not lockable, and there was no signage indicating the presence of oxygen cylinders. The Maintenance Director acknowledged the oversight, noting that the cylinders should have been stored in the designated Oxygen Storage room. On Unit 5, an E-sized oxygen cylinder was stored in the Oxygen Storage/Clean Linen room, just three inches from a metal rack containing various linens. Additionally, a C-sized and an E-sized oxygen cylinder were found free-standing and unsecured in a resident's room, between a wooden dresser and wardrobe. The Maintenance Director was unaware of this improper storage and confirmed that staff were instructed to secure oxygen cylinders in a cart or rack. Despite daily checks of oxygen storage rooms, these deficiencies were not addressed, indicating lapses in adherence to safety protocols.
Plan Of Correction
Plan of Correction: Approved January 9, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. A full facility audit of all oxygen storage areas was conducted to ensure that oxygen cylinders were properly stored, and proper signage was in place. A full facility audit was conducted of all storage and utility rooms to ensure that oxygen cylinders were not improperly stored in these rooms and where oxygen storage cabinets exist, that proper signage was in place and that doors were lockable. A full facility audit of all resident rooms was conducted to ensure that all oxygen cylinders were properly stored, and proper signage was in place. Two E Oxygen Cylinders were placed back in the proper storage areas during survey. The cardboard boxes of disposable gowns and shields were removed from the area during survey. Signage for the door was placed on door and door was repaired allowing the door to latch. The oxygen cylinders on Unit 5 were placed back in the proper storage units during survey. The oxygen cylinder located on unit 5, a c sized cylinder, was placed in the oxygen room during survey. The oxygen cylinder in resident room [ROOM NUMBER] was removed from room and placed in oxygen storage area during survey. 2. All residents are at risk for oxygen cylinders being placed 5 feet from combustible materials, room where oxygen was stored is not lockable and no signage in room where oxygen is stored and oxygen cylinders free standing and unsecured. 3. The Policy Oxygen Supplies and Concentrators Inventory revised 12/24 to include the verbiage regarding oxygen cylinders being stored less than five feet from combustible materials, doors to rooms that oxygen cylinders were being stored in being lockable, room that oxygen cylinders were being stored in having signage indicating that oxygen cylinders were being stored in that room, and oxygen cylinders not being stored free standing and unsecured was reviewed by the Consultant, no revision was necessary. 4. All facility staff will be in-serviced on proper storage of medical gases by the Consultant, (NAME) J Pietrowski, MSN RN LNHA. 5. Five audits will be conducted weekly on oxygen cylinders being placed within 5 feet from combustible materials, ensuring door to oxygen room is properly locked. Signage is available where oxygen is stored and oxygen is in secured storage. Any deficient practices will be immediately corrected and brought to QAPI for further review. Person Responsible: Maintenance Director Person Responsible: Maintenance Director
Penalty
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