Unsecured Oxygen Cylinder at Nurse’s Station
Penalty
Summary
The facility failed to provide a safe environment by not securely storing one of two oxygen cylinders observed at a nurse’s station. During observation, two oxygen cylinders were seen next to the crash cart behind the nurse’s station, with one cylinder properly secured in a rack and the other left unsecured. Later observation and interview with an LVN confirmed the oxygen tank was not secured; the LVN stated she had just started her shift, had not noticed the unsecured tank, and acknowledged it should always be secured in a rack because it was a hazard and could cause a fire. In a subsequent interview, the DON stated she was not aware the tank was unsecured, explained that night shift staff had been tasked with checking crash carts and had probably changed out the tank and forgotten to return it to the storage room, and stated her expectation that tanks be secured at all times because they could be knocked over. The DON also reported that the facility did not have a policy on oxygen storage, despite NFPA 99, 2012 Edition, Section 11.6.2.3 requiring freestanding cylinders to be properly chained or supported in a proper cylinder stand or cart. No specific residents were identified as directly involved at the time of the observation, and no resident medical histories or conditions were described in relation to this deficiency.
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