Unsecured Oxygen Cylinder Found in Resident Room
Penalty
Summary
A deficiency was identified when an unsecured oxygen (O2) tank was observed in a resident's room, standing upright in front of the dresser drawers and not attached to any medical device. The facility's policy on Medical Gas Cylinder Storage requires all freestanding O2 cylinders to be secured in a rack, on a cart, in a portable holder, in a storage cabinet, or with a chain. The resident involved had multiple diagnoses, including dependence on supplemental oxygen, dyspnea, recurrent pneumonia, Alzheimer's disease, COPD, type 2 diabetes mellitus, and dementia. The resident's assessment indicated intact cognition and a need for supervision to partial assistance with activities of daily living. Staff interviews confirmed that O2 cylinders should not be stored unsecured in resident rooms and should be kept in the supply room or properly attached to a wheelchair when in use. The Certified Nurse Aide (CNA) and the Director of Nursing (DON) both stated that extra cylinders should not be present in resident rooms and must be stored according to policy. The observation of the unsecured O2 tank in the resident's room was not in compliance with the facility's established procedures for safe storage of medical gas cylinders.