Unsecured Treatment Cart and Improper Oxygen Cylinder Storage
Penalty
Summary
The facility failed to ensure that two residents were free from accident hazards due to lapses in supervision and improper storage of potentially harmful items. For one resident with severe cognitive impairment and moderate dementia, a wound treatment cart containing various topical medications and antiseptics was observed unlocked and unattended in a common area near the resident. The resident was seen rummaging through the cart multiple times, opening several drawers, while staff in the vicinity either did not intervene or failed to secure the cart. Interviews with nursing staff revealed they were unaware the cart was unlocked and did not have keys to lock it, despite facility policy requiring all medication storage areas to be locked when unattended. Another resident, also with significant cognitive impairment and a diagnosis of chronic obstructive pulmonary disease, had a freestanding oxygen cylinder (E-Tank) stored unsecured next to their nightstand and near their roommate's bed. The E-Tank was observed on multiple occasions over two days in the same unsecured position. Staff interviews confirmed that oxygen cylinders should not be left in resident rooms when not in use and, if present, must be secured in a cylinder stand or to a wheelchair. The E-Tank was neither secured nor properly stored according to facility policy and national fire safety codes. These deficiencies were confirmed through direct observation by surveyors and corroborated by staff interviews, which acknowledged the lapses in following established safety protocols for medication and oxygen storage. The facility's own policies and national safety standards were not adhered to, resulting in residents having access to accident hazards.