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Based on interview and record review, the facility failed to have an effective system to motitor the oxygen supply to ensure the oxygen was readily available for emergency procedures.

Findings include:

Review of the facility logs to monitor the levels of oxygen in the delivery system, dated March 2021 thru October 2021, reflected that the system was only monitored on Monday, Tuesday, and Wednesday when the assigned EMS staff was on duty.

During an interview on 10/6/2021 with staff #2, he revealed that the Human Resource Manager was responsible for the monitoring of the oxygen system.

During an interview on 10/6/21 with staff #8, he stated that "I am in charge of HR. I am not in charge of the oxygen."

During an interview on 10/6/21 with staff # 10, he stated that "since they fired the maintance person in March of this year, I do daily rounds on Monday, Tuesday, and Wednesday. I change out the oxygen tanks when they get to 500. The plan was to have maintance check the oxygen on Thursday and Fridays. I don't think there was anyone scheduled to check the system on the weekends."

The facility has no policy on monitoring the oxygen system at this time.

The staff #2 confirmed this information on 10/6/21.

Based on observation, interview and record review, the facility failed to safely secure large medical oxygen tanks, to prevent them from falling and exploding.

Findings include:

Observations made during a tour of the facility's oxygen storage, on the afternoon of 10/6/21, revealed two storage areas. An outside storage area, sharing a wall with the facility's emergency room, contained 25 large oxygen cannisters; the cannisters were not chained or secured to prevent them from falling. A second oxygen storage area, located approximately 50 feet from the hospital, contained 13 large oxygen cannisters that were not secured.

On 10/06/21, during a tour of the facility's oxygen storage areas, Staff #3, Chief Nursing Officer, confirmed the findings and stated, "The oxygen should be secured."

Review of the facility provided policy, COMPRESSED GAS AND OXYGEN USE (REVISED: June 1,20) reflected, "Cylinders must be secured at all times so they cannot fall."

Based on interview and record review, the facility failed to have a QAPI (Quality Assurance and Performance Improvement) that was ongoing and comprehensive.

Findings include:

Review of occurrence reports, dated 10/30/2020, revealed that the facility oxygen system alarmed at 03:55 am indicating low oxygen levels in the oxygen delivery system. The facility contacted Staff #8 and the call went to voicemail at 03:56 am. The facility then contacted staff #2 at 0358 am and he said "we'll be there in a few minutes." At 04:08 am the staff tried to contact staff #8 again and the call went to voicemail. The staff then contacted the sheriff to go to Staff #8's house and wake him up. Staff #8 arrived at 04:37 am to change out the oxygen delivery system oxygen tanks.

Review of the Nurse Staff Meeting Agenda and Notes, dated 11/24/2020, revealed the occurrence was discussed and more portable oxygen tanks were ordered.

Review of the QAPI minutes reflected that there were no QAPI meetings from March 2020 until January 2021. The occurrence was not addressed in QAPI.

During an interview on 10/6/2021, Staff #2 stated that the Medical Director does not review the occurrence reports unless they pertain to medical staff so he wouldn't have reviewed this occurrence.

Review of patients that were on oxygen on the night of the occurrence revealed that no patients had a decrease in oxygen levels during this time.

Based on interview and record review the facility's QAPI (Quality Assurance and Performance Improvement) failed to address outcome indicators related to the prevention and reduction of adverse events.

Findings include:

Reciew of occurance reports datad 10/30/2020 revealed that the facility oxygen system alarmed at 03:55 am indicating low oxygen levels in the oxygen delivery system. The facility contacted the Staff #8 and the call went to voicemail at 03:56 am. The facility then contacted staff #2 at 0358 am and he said "we'll be there in a few minutes. At 04:08 am the staff tried to contact staff #8 again and the call went to voicemail. The staff then contacted the sheriff to go to Staff #8's house and wake him up. Staff #8 arrived at 04:37 to change out the oxygen delivery system oxygen tanks.

Review of the Nurse Staff Meeting Agenda and Notes, dated 11/24/2020 the occurance was discussed and more portable oxygen tanks were ordered.

Review of the QAPI minutes reflected that there were no QAPI meetings from March 2020 until January 2021. The occurance was not addressed in QAPI.

During an interview on 10/6/2021 Staff #2 stated that the Medical Director does not review the occurance reports unless they pertain to medical staff so he wouldn't have reviewed this occurance.

Review of patients that were on oxygen on the night of the occurance revealed that no patients had a decrease in oxygen levels during this time.