| 99 |
ST JOHN'S LUTHERAN HOME |
275024 |
3940 RIMROCK RD |
BILLINGS |
MT |
59102 |
2017-11-08 |
328 |
E |
1 |
1 |
8YVD11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure respiratory care, specifically oxygen therapy, was provided for 3 (#s 6, 26 and 27) of 27 sampled and supplemental residents. Findings include: 1. Resident #6 was admitted with [DIAGNOSES REDACTED]. Review of resident #6's Significant Change MDS, with an ARD of 8/3/17, reflected the resident had a cognitive decline with a BIMS score of 12, moderately impaired. The cognitive decline was added to resident #6's care plan. The MDS reflected resident #6 received the respiratory treatment of [REDACTED].#6 required supervision and set up for her activities of daily living. Review of resident #6's physician orders, dated 4/27/17, reflected an order for [REDACTED]. Review of resident #6's care plan reflected a problem, with the effective date of 4/27/17, for a potential for alteration in gas exchange and ineffective breathing pattern related to heart failure. The goal listed reflected the resident's oxygen saturation level would be maintained at 90%. The interventions listed reflected the resident was to be provided oxygen at up to 2 lpm to maintain a saturation level at or above 90% per nasal cannula. Another intervention reflected resident #6 could operate her concentrator, but generally needed help with turning the portable cylinders on and off that she used to go to activities and meals outside of her room. Another care plan problem, with the effective date of 8/19/17, reflected the resident had a compromised short-term memory as manifested by a BIMS score of 12 (down from 15 on admission). Interventions listed for the problem reflected the resident required staff to reassure her when she was confused, explain all procedures before performing them, and give verbal reminders and cues to assist the resident in orientation. Another care plan problem, with the effective date of 8/10/17, reflected an actual/potential alteration in self-care/ADL ability related to heart failure. Listed in the interventions were instructions for staff to supervise and assist resident #6 as needed during tasks. During an observation and interview on 11/6/17 at 2:50 p.m., resident #6 was sitting in her room in her wheelchair looking out of her window. The resident's nasal cannula was in her nose, and was attached to the oxygen concentrator. The oxygen concentrator was not turned on. Resident #6 stated the staff had put her cannula on her when she got back from lunch. Resident #6 stated she did not notice the oxygen concentrator was not turned on. Staff member I turned on resident #6's oxygen concentrator and stated it should have been turned on. During an interview on 11/7/17 at 9:30 a.m., resident #6 stated she normally takes care of her oxygen and turns on her concentrator when she gets back to her room. Resident #6 stated she forgets to turn it on sometimes. Resident #6's Significant Change MDS, with an ARD of 8/19/17, reflected she had a decline in her short-term memory and required reminders and cues to assist her in her orientation. During an interview on 11/7/17 at 10:10 a.m., staff member J stated resident #6 turns her oxygen on independently. Staff member J stated the resident knows she needs to use the oxygen. Staff member J stated staff reminds her she needs to use the oxygen. During an observation and interview on 11/7/17 at 12:32 p.m., resident #6 was sitting in the dining room eating lunch. The oxygen cylinder was hanging on the back of her wheelchair, and the needle on the gauge reflected the cylinder was on empty. The resident did not exhibit signs of being short of breath and did not have any complaints. The resident was not aware the oxygen cylinder was empty. At 12:47 p.m., resident #6 left the dining room and went to her room. Her oxygen cylinder reflected empty and no staff assisted the resident to get another cylinder or check to ensure it still had oxygen in it. When the resident entered her room, she sat looking out of her window. The oxygen concentrator was running in the on position, but the resident did not put on the nasal cannula that went to the concentrator. At 12:49 p.m., staff member K entered the resident's room and asked her if she would like some ice water. Resident #6 stated she would like some ice water. At 12:50 p.m., resident #6 stood up from her wheelchair and staff member K brought in the ice water and asked the resident if she wanted to lay down and if she needed assistance. Resident #6 stated she was going to go to the bathroom. Staff member K left the room and did not check the oxygen tank or concentrator prior to leaving. At 1:02 p.m., resident #6 came out of the bathroom, removed the nasal cannula that was attached to the oxygen cylinder, and put on the nasal cannula attached to oxygen concentrator. Resident #6 had been without oxygen therapy from the time of the dining room observation at 12:32 p.m. until she placed herself on the oxygen concentrator at 1:02 p.m. During an interview on 11/7/17 at 3:40 p.m., resident #6 stated she did not know how to check her oxygen cylinder. She stated she thought staff needed to check the cylinder to make sure they had oxygen in them. Resident #6 stated when she woke up this morning she wasn't feeling well. Resident #6 stated she woke up with her nasal cannula in her hand. Resident #6 stated she believed she was not feeling well because she had taken off her oxygen in her sleep. Resident #6 stated she would want staff to wake her to put on her oxygen if they saw it was off. 2. Resident #26 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #26's Quarterly MDS, with an ARD of 8/24/17, reflected the resident received the respiratory treatment of [REDACTED]. The MDS reflected the resident did not resist care and required extensive assistance of one person with her ADLs. Review of resident #26's physician orders, dated 1/19/16, reflected the resident was to be provided with oxygen therapy per nasal cannula at 2 lpm to maintain a saturation level of 90% or above. Review of resident #26's care plan reflected a problem, with the effective date of 6/8/17, of alteration in resident #26's thought process related to a history of stroke with [MEDICAL CONDITION]. Interventions listed included for staff to give resident #6 short simple instructions, and provide a consistent routine environment. Another problem, with the effective date of 6/8/17, reflected a potential for alteration in gas exchange and ineffective breathing pattern related to [MEDICAL CONDITION]. Interventions listed included oxygen at 2 lpm per nasal cannula to maintain oxygen saturation at or above 90%, encourage resident #26 to deep breathe, and breathe through the nasal cannula if in place. During a meal time observation on 11/7/17 at 12:30 p.m., resident #26's oxygen cylinder was on empty. The empty oxygen cylinder was reported to staff member P by this surveyor. Staff member P observed the oxygen cylinder and instructed staff member K to obtain a new oxygen cylinder to replace the empty one. At 12:40 p.m. staff member K returned with a new oxygen cylinder and changed out the empty cylinder. Staff did not check resident #26's oxygen saturation prior to applying the new oxygen cylinder. 3. Resident #27 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #27's physician orders reflected the resident required oxygen at 2 lpm per nasal cannula. Review of resident #27's most current Annual MDS, with an ARD of 8/24/17, reflected the resident was not receiving a respiratory treatment during that assessment time. Resident #27's MDS reflected he had a BIMS of 14, cognitively intact. Resident #27 required extensive assistance of one person with his activities of daily living. Review of resident #27's care plan reflected a problem, with an effective date of 9/12/16, for an alteration in resident #27's thought process related to dementia. Interventions listed included for staff to give short simple instructions and reorient as needed. Another problem, with the effective date of 9/12/17, reflected an actual/potential alteration in self-care/ADL ability related to dementia with mild confusion. Interventions listed included for staff to supervise and assist as needed during tasks. During an observation on 11/7/17 at 1:05 p.m., resident #27 was in the dining room for lunch and had an oxygen cylinder attached to his wheelchair that he was receiving oxygen from, per nasal cannula. The gauge on the oxygen cylinder was in the red zone and was at the 200 psi mark. The resident was assisted back to his room from the dining room. The resident was not placed on his oxygen concentrator from the oxygen cylinder. The resident was sitting next to his bed and was visible from the doorway. At 1:07 p.m., staff member Q passed by the resident's room with the medication cart and did not place the resident on the oxygen concentrator. At 1:09 p.m., staff member R walked past resident #27's room, looked in on the resident from the door and did not place the resident on the concentrator. The resident was reading a newspaper and facing the window away from his door. The surveyor interviewed the resident as soon as staff member R walked away. The resident stated he was ok and did not notice his oxygen tank was on empty. During an interview on 11/7/17 at 1:10 p.m., staff member J was notified by the surveyor that resident #27 was not placed on his oxygen concentrator and his tank gauge showed it was in the red zone. Staff member J stated resident #27 had a health issue last Friday for a GI bleed and [MEDICAL CONDITION]. Staff member J stated resident #27 needed to be on oxygen continuously. Staff member J went into resident #27's room, and placed him on his oxygen concentrator. During an interview on 11/7/17 at 3:20 p.m., staff member S stated the night shift CNAs check the oxygen cylinders and change them out if needed. Staff member S stated staff should check the oxygen cylinder before they take the resident out of their room to ensure it had enough oxygen in it. During an interview on 11/7/17 at 3:30 p.m., staff member T stated staff check the oxygen cylinders on night shift and throughout the day, usually at the end of the shift. Staff member T stated it depended on if the resident was mobile and if the oxygen was continuous or had a gauge with an on-demand setting. Staff member T stated sometimes it was hard to check if the resident was independent. Staff member T stated the oxygen cylinders lasted approximately two hours if they were on continuously. During an interview on 11/8/17 at 8:35 a.m., staff member J questioned if resident #27's oxygen was in the red zone. Staff member J stated if the gauge got to the beginning of the red zone, 500 psi, the resident would have approximately 1.25 hours left. Staff member J showed a picture of resident #27's gauge at the time she was notified of the concern on 11/717 at 1:10 p.m. The picture showed the needle to be at the 200-psi mark. The staff should have changed out the oxygen cylinder according to the facility policy and procedure to ensure it did not go below the 200 psi mark. Review of the facility policy titled, St. [NAME]'s Lutheran Portable Oxygen Therapy Use, reflected instructions for staff to, change the cylinder when the needle gets to the lower part of the red section. The policy reflected, Be sure to change the cylinder before the needle gets below 200-psi. During the interview on 11/7/17 at 8:35 a.m., staff member J stated if staff took a resident to their room they should place the resident on the oxygen concentrator from the oxygen cylinder. Staff assisted resident #27 to his room and did not place him on the oxygen concentrator. |
2020-09-01 |