cms_GA: 2370
Data source: Big Local News · About: big-local-datasette
rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
2370 | DADE HEALTH AND REHAB | 115558 | 1234 HIGHWAY 301 SOUTH | TRENTON | GA | 30752 | 2017-08-10 | 309 | D | 0 | 1 | JLS811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to follow the physician's order to obtain and document oxygen (O2) saturation with use of pulse ox meter as needed (PRN) for shortness of breath (SOB) for one (1) resident (R#44) who receives O2 therapy of 22 sampled residents. Findings Include: Record review for R#44 revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of the physician's order for R#44 revealed an order to obtain and document oxygen saturation with use of pulse ox meter PRN for SOB and notify MD if less than ( Record review of the May, June, (MONTH) and (MONTH) (YEAR) medication administration record (MAR) for R#44 revealed no documentation of O2 saturation for the days of which O2 was administered. Observation of R#44 on 8/9/17 at 10:38 a.m. revealed resident in bed wearing a nasal cannula with O2 at 3 liters per minute (lpm) from oxygen concentrator. Observation of R#44 on 8/9/17 at 12:31 p.m. revealed resident sitting in wheelchair outside on the patio wearing nasal cannula with O2 at 3 lpm from [NAME] (type of O2 cannister) cylinder tank. Observation of R#44 on 8/10/17 at 11:00 a.m. revealed resident sitting in wheelchair in lobby visiting with her daughter. The resident was wearing a nasal cannula with O2 at 3 lpm from [NAME] cylinder tank. During an interview with the Administrator on 8/10/17 at 10:00 a.m. she revealed the facility does not have a policy related to oxygen administration or for following physician's orders. During an interview with License Practical Nurse (LPN) DD on 8/10/17 at 11:29 a.m. she stated she places the resident on oxygen when the resident becomes SOB. She also stated today the resident is on oxygen because she became short of breath after taking a shower. The LPN DD stated she documents on the MAR the reason for the PRN oxygen but she does not document the residents' O2 saturation on the MAR. During an interview with the Director of Nursing (DON) on 8/10/17 at 12:24 p.m. she stated she expects the nurse to administer oxygen to this resident per physician order as needed for SOB or difficulty breathing. The DON also stated she expects the nurse to document the reason for administering the oxygen in the nurses' notes, obtain O2 saturations when resident is SOB and document to O2 saturation on the MAR. The DON confirmed the O2 saturations have not been documented on the MARs for the months of May, June, (MONTH) and (MONTH) (YEAR) when oxygen was administered. | 2020-09-01 |