Failure to Secure Portable Oxygen Cylinder
Penalty
Summary
Staff failed to properly store and secure a portable oxygen cylinder for a resident who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia, Anxiety Disorder, and Muscle Weakness. The resident was cognitively intact, as indicated by a BIMS score of 15, and had a physician's order for oxygen at 2.5 LPM via nasal cannula to manage hypoxia related to their respiratory conditions. The care plan included interventions for staff to observe breath sounds, administer oxygen per medical orders, and monitor for respiratory distress. During observations conducted in the resident's room, a portable oxygen cylinder was found unsecured and free-standing between a dresser and a chair. Interviews with an LPN and the Director of Nursing confirmed that the oxygen cylinder should not have been left free-standing and should have been secured in a roller, sling bag, or the designated oxygen storage room, in accordance with the facility's oxygen safety policy. This failure to secure the oxygen cylinder constituted a deficiency in ensuring the area was free from accident hazards.