cms_GA: 72
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 72 | WILLIAM BREMAN JEWISH HOME, THE | 115022 | 3150 HOWELL MILL ROAD N.W. | ATLANTA | GA | 30327 | 2017-03-30 | 328 | E | 0 | 1 | U5BR11 | Based on observations, record review, policy and procedure review, and staff interviews the facility failed to maintain clean inlet filters on oxygen concentrators for five residents (R) receiving oxygen therapy ( R#80, R#182, R#181, R#111, R#96). The sample size was 7 residents receiving oxygen therapy via oxygen concentrators. Findings include: 1. Observation on 3/28/17 at 2:47 p.m. revealed R # 182 lying in bed awake receiving oxygen by nasal cannula at 3 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. Physician order: oxygen at 3 liters by nasal cannula every shift. Observation on 3/29/17 at 9:47 a.m. revealed R # 182 lying in bed awake receiving oxygen by nasal cannula at 3 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. 2. Observation on 3/28/17 at 3:22 p.m. revealed R # 181 lying in bed with eyes closed receiving oxygen by nasal cannula at 2 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. Physician order: oxygen 2 - 5 liters as needed by nasal cannula to keep oxygen level above ninety (90) percent. Observation on 3/29/17 at 9:48 a.m. revealed R # 181 lying in bed with eyes closed receiving oxygen by nasal cannula at 2 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. 3. Observation on 3/28/17 at 3:35 p.m. revealed R # 111 seated in recliner chair at bedside receiving oxygen by nasal cannula at 3 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. Physician order: oxygen continuously at 3 liters by by nasal cannula at night and 3 liters as needed during the day. Observation on 3/29/17 at 10:26 a.m. revealed R # 111 asleep in bed, private sitter at bedside. R # 111 is receiving oxygen by nasal cannula at 3 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. 4. Observation on 3/28/17 at 3:38 p.m. revealed R # 96 lying in recliner chair at bedside receiving oxygen by nasal cannula at 2 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. Physician order: oxygen continuously at 2 liters by nasal cannula or face mask to keep saturation above ninety (90) percent. Observation on 3/29/17 at 10:06 a.m. revealed R # 96 in bed, CNA at bedside providing morning care. R # 96 is receiving oxygen by nasal cannula at 2 liters per minute(LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. Observation with the Director of Nursing (DON) on 3/29/17 from 4:35 p.m. to 4:58 p.m. confirmed the oxygen concentrators for R # 181, R # 182, R # 111, R # 207 had one filter on the right side of the machine coated with dust. Facility Policy on Departmental (Respiratory Therapy) - Prevention of Infection stated that filters from oxygen concentrators should be washed every 7 days with soap and water, rinse and squeeze dry, allow filter to dry prior to replacing back into machine. Telephone interview with LPN AA on 3/30/17 at 10:45 a.m. Stated that she works 3rd shift on the 3rd floor, and part of her duties include cleaning the oxygen concentrator filters on that floor weekly every Thursday, but she was off last week Thursday and Friday. Stated also that she did not follow up on 3/27/17 to ensure the oxygen concentrator filters were cleaned after resuming her normal work schedule. Telephone interview with LPN BB on 3/30/17 at 11:19 a.m. stated that she works 3rd shift on the 2nd floor and part of her duties include cleaning the oxygen concentrator filters on that floor with soap and water, air dry, and replace them every Thursday of every week, but forgot to clean them last week. Telephone interview with LPN CC on 3/30/17 at 3:00 p.m. stated that she started working on the 5th floor 3rd shift Wednesday last week, but did not clean the oxygen concentrator filters on that floor because she was not told during orientation that it was part of her duties to get the filters cleaned every week. Stated that she was only given that information yesterday by her supervisor. Interview with DON on 3/30/17 at 11:05 a.m. stated that there was no flow sheet or documentation to show when the oxygen concentrator filters were cleaned. However, she stated that as of yesterday she added a flow sheet to the Treatment Administration Record for all residents receiving oxygen. 5. On 3/27/17 at 12:53 p.m., the filter on the back of R #80's oxygen concentrator was observed to be covered with a thick coating of a white, dust-like material. Further observation at this time revealed that the tubing for the nasal cannula that delivered the oxygen to the resident was dated 3/21. During observation on 3/27/17 at 4:15 p.m. and 3/28/17 at 9:10 a.m., the nasal cannula tubing was dated 3/27/17, 7-3 (7:00 a.m. to 3:00 p.m. shift). Further observation revealed that there was still a thick coating of a white dust-like material on the oxygen concentrator filter. | 2020-09-01 |