Oxygen Tank Present in Smoking Area with Resident
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and used a wheelchair and walker for mobility, was observed in the designated smoking area with a portable oxygen tank secured to her wheelchair. The resident was present while five other residents were actively smoking, although her oxygen tank was not in use and was later found to be empty. The Director of Nursing (DON) distributed cigarettes to the other residents and assisted them in lighting their cigarettes, but did not initially notice the oxygen tank attached to the resident's wheelchair. The situation was brought to the attention of the Interim Administrator by the State Agency, prompting the DON to remove the oxygen tank from the resident's wheelchair and hand it to the Interim Administrator, who then carried the unsecured tank through the facility to the oxygen storage area. Interviews with staff and the resident confirmed that the resident typically kept an oxygen tank on her wheelchair and would notify staff when it was empty, but did not usually go outside during smoking times and no longer smoked herself. Staff acknowledged that even empty oxygen tanks could pose a flammability risk if near smoking residents. Facility policy required the removal of flammable items, including smoking articles, from areas where oxygen is administered, but did not address the safe transport of oxygen tanks. The failure to ensure the removal of the oxygen tank from the resident's wheelchair before entering the smoking area, and the subsequent handling of the tank, resulted in a lapse in accident prevention and supervision as required by facility policy and regulations.