| 794 |
CENTENNIAL PARK RETIREMENT VILLAGE |
285094 |
510 CENTENNIAL CIRCLE |
NORTH PLATTE |
NE |
69101 |
2017-01-26 |
328 |
G |
0 |
1 |
EUUX11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D6 Based on observations, record reviews and interviews; the facility failed to ensure that oxygen was in place and administered as ordered and that respiratory status was monitored for one sampled resident (Resident 39) who frequently removed oxygen resulting in low oxygen blood levels. The facility census was 50 with 17 current sampled residents and 2 closed records. Findings are: Review of the Resident Face Sheet revealed that Resident 39 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan, edited 1/20/17, revealed that the resident was at risk for impaired gas exchange related to chronic [MEDICAL CONDITION]. Approaches included administer oxygen per nasal cannula, assess and record signs of impaired gas exchange (confusion, restlessness, irritability), resident refuses to wear oxygen frequently, monitor oxygen saturation as ordered and monitor and document respiratory status as needed with changes in respiratory status. Interview with a family representative on 1/24/17 at 12:30 PM revealed they often found the resident without oxygen. Further interview revealed that the resident was more confused, restless and agitated when the oxygen wasn't kept on which made it even more difficult to get the resident to keep the oxygen in place. Observations on 1/24/17 at 8:45 PM revealed the resident seated in the wheelchair in room with oxygen cannula (tubing placed in the nose to administer supplemental oxygen) on the floor. Further observations revealed NA (Nursing Assistant) - M attempted to place the oxygen on the resident and the resident refused. NA - M reported to LPN (Licensed Practical Nurse)- H, Charge Nurse, that the resident refused the oxygen and was agitated. LPN - H entered the room and encouraged the resident to use the oxygen and the resident complied. LPN - H checked the resident's oxygen saturation which was 79% (normal oxygen saturation is greater than 90%). LPN - H encouraged the resident to take deep breaths and after several minutes the oxygen saturation was 80%. At 9:15 PM, LPN - H reported that a respiratory treatment was administered and then the resident's oxygen saturation rate was 90%. Observations of the resident on 1/24/17 at 9:45 PM revealed that the resident's oxygen was off and the cannula was draped over the arm of the wheelchair. Interview on 1/24/17 at 10:00 PM with NA - M revealed that the resident continued to refuse to get ready for bed. Observations on 1/25/17 at 4:30 AM, 5:30 AM and 6:00 AM revealed the resident sleeping in bed with the oxygen cannula off. Interview with RN (Registered Nurse) - L on 1/25/17 at 6:05 AM revealed that RN-L was not aware that the resident's oxygen had been off this morning. RN - L checked the oxygen saturation which was reported to be 86%. Observations on 1/25/17 at 7:00 AM revealed the resident sleeping in bed with the oxygen cannula off. Observations on 1/25/17 at 8:20 AM revealed MA (Medication Aide) - [NAME] awakened the resident for morning cares. MA - [NAME] shut the oxygen concentrator off. Further observations revealed that the resident did not have oxygen on during the morning cares. MA - [NAME] applied the oxygen for the resident at 8:50 AM. Review of the Nurses Notes revealed no notes after 1/11/17 which stated that the resident was off Medicare A skilled nursing services. There was no documentation of the resident's refusal to use oxygen as ordered, restlessness and agitation or low oxygen saturation levels. Review of the Treatments, dated (MONTH) (YEAR), revealed an order, dated 12/12/16, for oxygen at 2 liters per minute per nasal cannula continuously. Review of the Routine Medications, dated (MONTH) (YEAR), revealed an order, dated 12/12/16 for respiratory treatments four times a day. Review of the Respiratory Assessment Flow Sheet, dated (MONTH) (YEAR), revealed an assessment completed daily after a respiratory treatment which showed oxygen saturation levels of 94% - 98%, and lungs clear. Interview with the DON (Director of Nursing) on 1/26/17 at 8:30 AM confirmed that the nurses should monitor and document the resident's respiratory status, in addition to the daily assessment, as the resident was at risk for low oxygen saturation levels, increased restlessness, agitation and discomfort when the oxygen was removed. |
2020-09-01 |