F0689

J

Failure to Supervise Resident Using Stairwell with Oxygen

Washington, District Of Columbia Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

Facility staff failed to ensure adequate supervision and assistance to prevent accidents for Resident #4, who had COPD, chronic respiratory failure with hypoxia, and hypertension, and was receiving 2–3 L/min oxygen via nasal cannula per physician order. The resident’s care plan, revised on 10/29/25, specified that he was to use the stairs when going down and coming back in, with an escort. A Quarterly MDS showed he had intact cognition (BIMS 15), no functional impairment in range of motion, was independent with transfers and walking 150 feet, and used oxygen therapy.

On 01/30/26 at 3:47 PM, surveyors observed the resident alone in the 2-north stairwell, going down the stairs, noticeably short of breath, with oxygen at 3 L via nasal cannula, and carrying an E-tank oxygen cylinder in a wheeled caddy. The resident stated he did not like taking elevators and therefore used the stairs, and reported that a staff member had let him down to the stairwell, which required manual entry of a 4-digit code from the units. In a face-to-face interview shortly thereafter, the Administrator acknowledged that the resident used the stairwell due to claustrophobia and stated that he should have someone with him when using the stairs. The evidence showed that serious harm was likely to occur as the resident was short of breath, alone in the stairwell, and carrying an oxygen tank, demonstrating that facility staff did not provide adequate supervision as required under 42 CFR 483.25, F689.

Removal Plan

• Resident #4 was immediately assessed by a licensed nurse, including a head-to-toe assessment and fall risk assessment, with documentation entered in the electronic health record.
• Resident #4 received education by a licensed nurse regarding stair safety, safety with oxygen tank/portable oxygen use, oxygen tubing safety, fall precautions, and leave-of-absence (LOA) precautions.
• The Nurse Educator/designee initiated staff education for all staff on stair safety and resident supervision, including documentation of escort refusal; staff not yet educated will receive education when they come on shift.
• Resident #4's care plan was updated by a licensed nurse to reflect non-compliance with staff escort while using the stairwell.
• The stairwell entry code was changed and education was provided to all staff regarding the new code.