Failure to Secure Oxygen Tanks and Implement Fall Interventions
Penalty
Summary
The facility failed to secure 44 full E-pressurized medical oxygen tanks in a locked area, leaving them accessible in an unlocked storage room despite the presence of eight cognitively impaired, independently mobile residents. Multiple inspections over several days found the oxygen storage room door with a keypad that did not lock when shut, and staff interviews revealed confusion about whether the room should be locked. Facility policy required oxygen to be stored safely, but this was not followed, as confirmed by both direct observation and staff statements. Additionally, the facility did not ensure that fall prevention interventions for a resident with severe cognitive impairment, muscle weakness, and a history of falls were in place after she was moved to a new room. The resident's care plan required non-skid traction tape and signage to be present in her room, but an inspection found these interventions missing. Staff interviews confirmed that these fall interventions should have been transferred to the new room, and facility policy required staff to ensure interventions were implemented after a room change.