Failure to Remove Petroleum-Based Lotion from Oxygen Therapy Resident's Room
Penalty
Summary
A deficiency occurred when a facility failed to remove a petroleum-based lotion from the room of a resident who was receiving continuous oxygen therapy via nasal cannula. The resident, who had diagnoses including congestive heart failure and chronic respiratory failure, had a physician's order and care plan for continuous oxygen at 2 liters per minute. During an in-room observation, a container of petroleum-based lotion was found on the resident's overbed table while the oxygen concentrator was running and delivering oxygen into the environment. The resident reported that her husband had brought the lotion and that she had used it previously on her arms, but not on her face or lips, and had not been informed by the facility that petroleum-based lotions should not be used while on oxygen. The assigned nurse confirmed that the resident should not use petroleum-based lotion while receiving oxygen due to fire risk and stated she was unaware the lotion was present in the room. The nurse removed the lotion after it was discovered. The DON also acknowledged that the resident should not have had petroleum-based lotion in her room and admitted to overlooking the lotion during a prior room check. The facility's failure to identify and remove the petroleum-based lotion from the resident's environment while she was receiving oxygen constituted the deficiency.