Flammable Lip Balm Found Near Resident Receiving Oxygen Therapy
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following cerebral infarction, acute respiratory failure with hypoxia, diabetes mellitus, neuromuscular dysfunction of the bladder, and allergic rhinitis was observed receiving oxygen therapy at 2L/min via nasal cannula. During observation, a tube of Carmex lip balm containing 45.3% white petrolatum was found on the resident's bedside table. The resident reported using the lip balm for moisture. Facility records indicated that the resident was severely cognitively impaired and required extensive assistance with activities of daily living. Interviews with the DON and an LVN revealed that staff were unaware of the flammable nature of the lip balm and its incompatibility with oxygen therapy. The DON acknowledged that the resident should not have had the Carmex while on oxygen and that oxygen can react with oily substances, potentially causing burns. Facility policy and NFPA guidelines both specify that oil-based products should be kept away from oxygen in use, but these precautions were not followed, resulting in the presence of a flammable substance near the resident's oxygen supply.