Unsecured Oxygen Tank Creates Accident Hazard
Penalty
Summary
The facility failed to ensure an environment free from potential accident hazards by not properly securing an oxygen (O2) tank for a resident receiving oxygen therapy. Observations on multiple occasions revealed a free-standing, unsecured O2 tank located behind the resident's bed. The resident had diagnoses including acute respiratory distress and heart failure, and a moderate cognitive impairment as indicated by a BIMS score of 11. The resident had a physician's order for oxygen as needed at two liters per minute. Staff interviews confirmed that free-standing O2 tanks should not be stored in residents' rooms, as they could easily fall and cause injury. A CNA admitted to forgetting to remove the tank after patient care, and an RN was initially unsure of the policy due to being newly employed. The DON confirmed that under no circumstances should a free-standing O2 tank be stored in a resident's room and acknowledged that the tank had been present since the resident's recent readmission. The facility did not have a policy on accident hazards available for review.