cms_ND: 70
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 70 | MINOT HEALTH AND REHAB, LLC | 355031 | 600 S MAIN ST | MINOT | ND | 58701 | 2017-07-26 | 328 | D | 0 | 1 | GH6U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of professional reference, review of facility policy, and staff interview, the facility failed to provide the necessary care and services for 2 of 5 sampled residents (Resident #4 and #13) receiving oxygen therapy. Failure to follow the physician's orders and provide guidance to facility staff on oxygen usage does not allow the facility or the health care provider to assess the effectiveness of the resident's oxygen therapy. Findings include: Berman and Snyder, S., Kozier & Erb's Fundamentals of Nursing Concepts, Process, and Practice, 10th ed., Pearson Education, Inc., New Jersey, page 1259 states, . Like any medication oxygen is not completely harmless to the client. Clients can receive an inadequate amount or an excessive amount of oxygen and both can lead to a decline in the client's condition. Review of the facility policy titled Oxygen Administration occurred on 07/26/17. This policy, dated (MONTH) 2010, stated, . Review the physician's orders or facility protocol for oxygen administration. Adjust the oxygen delivery device so that . the proper flow of oxygen is being administered. - Review of Resident #4's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS), dated [DATE], identified severely impaired cognition and oxygen use. The current care plan identified, . O2 (oxygen) on at 2L/min (liters per minute) via nasal cannula to keep sats (oxygen saturation) > (greater than) 90%. Monitor O2 SATS q (every) shift. respiratory impairment related to: history of hospitalization for pneumonia, [MEDICAL CONDITIONS] . evaluate lung sounds and VS (vital signs) . A current physician order, dated 06/29/17, identified, oxygen @ 2L/MIN via NC (nasal cannula) to keep O2 SATS > 90%. Monitor SATS every shift. A progress note, dated 07/18/17, stated, . admitted to hospital . [MEDICAL CONDITION] . left sided pleural effusion . The Treatment Administration Record (TAR) and weights and vitals summary, dated (MONTH) 01-24, (YEAR), identified no documentation on Resident #4's oxygen usage for the following dates/times: * 07/02/17 day shift * 07/06/17 night shift * 07/11/17 day shift * 07/20/17 night shift * 07/21/17 day and night shift Observations showed the following: * 07/24/17 at 10:20 a.m., Resident #4 laid in bed without oxygen on. Staff failed to continuously provide oxygen to Resident #4. * 07/24/17 at 3:55 p.m., two certified nursing assistants (CNAs) (#8 and #9) provided perineal cares for Resident #4. One CNA (#8) removed the oxygen nasal cannula tubing from the resident and then the two CNAs (#8 and #9) transferred Resident #4 into her wheel chair/recliner. One CNA (#8) asked Resident #4 if she wears oxygen when she is up in the chair. Resident #4 stated she was unsure. The CNA (#8) shut off the oxygen concentrator and both CNAs exited the room. The CNA failed to clarify with a staff nurse if Resident #4 required oxygen continuously. * 07/24/17 at 5:40 p.m. and 6:00 p.m , Resident #4 sat in the wheel chair/recliner in the dining room without oxygen on. * 07/25/17 at 8:05 a.m., two CNAs (#11 and #12) entered Resident #4's room, removed the oxygen nasal cannula from the resident, shut off the oxygen concentrator, transferred her from the bed to the wheel chair/recliner, and brought her to the dining room. The CNAs failed to reapply the oxygen. * 07/25/17 at 8:50 a.m. and 9:20 a.m., Resident sat in wheel chair/recliner without oxygen on. * 07/25/17 at 11:55 a.m., two CNAs (#11 and #13) entered Resident #4's room, removed the oxygen nasal cannula tubing from the resident, shut off the oxygen concentrator, transferred her from the bed to the reclining wheelchair, and exited the room. The CNAs failed to reapply the oxygen. * 07/25/17 at 12:25 p.m., Resident #4 sat in the wheel chair/recliner in the dining room without oxygen on. * 07/26/17 at 11:07 a.m., Resident #4 laid in bed without oxygen on. A CNA (#15) and a staff nurse (#16) entered Resident #4's room, provided wound cares, and then exited the room. The facility staff failed to apply and provide oxygen to Resident #4. 07/26/17 at 12:00 p.m., 1:00 p.m., and 2:00 p.m., Resident #4 laid in bed without oxygen on and the oxygen concentrator turned off. During an interview on 07/25/17 at 11:30 a.m., a nurse manager (#14) confirmed staff should ensure Resident #4's oxygen is administered at 2L/MIN and on at all times per nasal cannula. Resident #4's oxygenation levels drop down to 80% when the oxygen is not administered continuously. The nurse manager (#14) stated she expects the staff nurse to document oxygen use for Resident #4 every shift. During an interview on 07/26/17 at 2:00 p.m., an administrative staff member (#3) verified staff are expected to ensure the consistency in delivery of Resident #4's oxygen at 2L/NC continuously. The facility failed to consistently provide Resident #4's oxygen. - Review of Resident #13's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. A current physician order, dated 06/26/17, identified, oxygen @ 2L/NC to maintain O2 SATS check each shift. Observations on 07/26/17 showed: * 12:15 p.m., Resident #13 sat in a wheel chair in the dining room with continuous oxygen on at 2L/NC per portable oxygen tank. * 2:05 p.m., Resident #13 laid in bed with continuous oxygen on at 3L/NC per oxygen concentrator. During an interview on 07/26/17 at 2:00 p.m., an administrative staff member (#3) verified staff are expected to ensure the consistency in delivery of Resident #13's oxygen at 2L/NC continuously. The facility failed to consistently provide Resident #13's oxygen at the ordered flow rate. | 2020-09-01 |