Failure to Ensure Safe Oxygen Transport and Timely Fall Documentation
Penalty
Summary
The facility failed to ensure a safe environment for residents by not following established procedures for transporting oxygen cylinders and by failing to document and respond to a resident fall that resulted in injury. Specifically, a nursing assistant was observed carrying a full oxygen tank by hand down the hallway, rather than using a required carrier or stand, in violation of facility policy designed to prevent accidental tipping and potential hazards. This incident was confirmed by both the nursing assistant and the Regulatory Compliance Officer. Additionally, a resident with Alzheimer's disease, dementia, and osteoporosis experienced a fall that was witnessed by his roommate and reported by a certified nursing assistant. However, there was no documentation of the fall in the resident's medical record, nor were any neurological checks, treatments, or follow-up actions recorded at the time of the incident. The nurse on duty during the fall did not document or address the event and subsequently resigned. The resident later returned to the facility with a spinal brace and was receiving intravenous antibiotics for a hip infection.