Failure to Secure Oxygen Tanks and Implement Fall Interventions
Penalty
Summary
Surveyors identified that the facility failed to secure pressurized supplemental oxygen tanks in a locked area, leaving 35 oxygen cylinders accessible in an unsecured storage room. The room had a key lock, but it was not secured at the time of observation, making the tanks accessible to 22 cognitively impaired, independently mobile residents. Staff interviews confirmed that facility policy required oxygen tanks to be stored in a locked room, and all interviewed staff acknowledged this expectation. Additionally, the facility did not ensure that fall prevention interventions were in place for two residents with severe cognitive impairment and significant physical limitations. One resident, with diagnoses including dementia, major depressive disorder, and a history of hip fracture, was found in bed with her call light on the floor and her fall mat folded and not in use. Her care plan required the call light to be within reach and the fall mat to be in place. Another resident, also with severe cognitive impairment and a history of falls, was observed with her call light on the floor, her fall mat folded at the head of the bed, and no nonskid strips in her bathroom, despite these being specified interventions in her care plan. Staff interviews revealed that all nursing staff had access to care plans and were responsible for ensuring fall interventions were in place before leaving a resident's room. Facility policy required staff to implement individualized fall prevention measures based on each resident's risk factors. Despite these policies and staff awareness, required interventions were not consistently implemented for the residents reviewed.