Unsecured Portable Oxygen Tank Found in Resident Room
Penalty
Summary
A portable oxygen tank was found standing upright and unsecured in the room of a resident with severe hypoxic ischemic encephalopathy and chronic respiratory failure. The tank was not attached to the wall, placed in a portable carrying device, or secured in any way, and lacked a regulator to determine the remaining oxygen. This was observed during a facility visit, and both a Licensed Practical Nurse and a Respiratory Therapist confirmed that all portable oxygen tanks, regardless of whether they are full or empty, should be secured at all times to prevent potential injury. Interviews with facility staff, including the Director of Nursing, revealed that checking for potential hazards in resident rooms is a shared responsibility among leadership and staff. The facility's policy on oxygen therapy requires that oxygen tanks be placed in approved stands to prevent rolling or accidental falls, and that empty tanks be stored separately from full tanks in designated storage areas. The unsecured tank in the resident's room was not in compliance with these established safety protocols.