Failure to Assess and Maintain Adequate Portable Oxygen Supply for Emergency Evacuation
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for the competent care of residents requiring continuous supplemental oxygen therapy during both routine operations and emergencies. Specifically, the facility assessment did not include information on the number of portable oxygen tanks needed to safely evacuate all residents with active physician orders for continuous oxygen in the event of an emergency, such as an earthquake. The assessment only indicated that central supply staff monitored and replenished emergency supplies but lacked details on the specific oxygen tank requirements for evacuation scenarios. At the time of review, there were 55 residents with active orders for continuous supplemental oxygen—51 in the subacute unit and four in the skilled nursing unit. However, the facility's inventory consisted of only 46 full portable oxygen tanks (43 E tanks and three H tanks), which was insufficient to meet the needs of all residents requiring continuous oxygen during an emergent evacuation. The Assistant Administrator confirmed that previous assessments had included this information, but the current assessment did not, resulting in a failure to ensure adequate resources for safe evacuation.