Unsecured Oxygen Cylinder Improperly Stored in Resident Room
Penalty
Summary
A deficiency was identified when an oxygen cylinder was found stored upright and unsecured in a resident's room. The resident, who had moderately impaired cognition, stated she did not know why the oxygen cylinder was in her room and was unaware if she was supposed to be receiving oxygen. Review of her medical records, including the quarterly MDS assessment, care plan, and current physician orders, confirmed that she was not receiving oxygen therapy and had no order for oxygen. The oxygen cylinder was observed to be approximately three-quarters full and remained in the resident's room over multiple observations. Nurse aides responsible for the resident acknowledged that the oxygen cylinder should have been stored in the designated oxygen storage room and secured in a holder to prevent it from falling. They could not recall how long the cylinder had been in the resident's room and stated they had not noticed it previously. The Director of Nursing confirmed that oxygen cylinders should not be stored in residents' rooms and should be secured in the storage room until needed.