Failure to Prevent Accident Hazards and Ensure Safe Supervision
Penalty
Summary
A deficiency was identified when a portable oxygen cylinder was observed unsecured and lying sideways on the seat of a wheelchair in a resident's room. The resident, who had diagnoses including chronic obstructive pulmonary disease, respiratory failure, and congestive heart failure, required oxygen therapy. Facility policy and OSHA regulations require that oxygen cylinders be stored upright and secured, but the cylinder was not in a holder or chained area as required. Another deficiency occurred when a resident with quadriplegia, congestive heart failure, and chronic obstructive pulmonary disease had a Q-tip lodged in their nostril. The resident was dependent on staff for care and unable to independently grasp objects. Despite a provider order to send the resident to the Emergency Department for Q-tip removal, facility staff removed the Q-tip themselves with tweezers and did not immediately send the resident to the hospital as ordered. Additionally, the facility did not complete an accident or reportable incident form for this occurrence. A further deficiency was found when a resident with dementia and generalized weakness sustained a skin tear after their hand became caught in a bed side rail. The resident was alert but confused and required maximum assistance for mobility and hygiene. The care plan did not indicate side rail use, and interviews and record review confirmed that a side rail assessment was not completed prior to the use of side rails, contrary to facility policy. The facility also failed to obtain informed consent or document side rail use in the resident's plan of care.