cms_OR: 29
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 29 | REGENCY GRESHAM NURSING & REHAB CENTER | 385015 | 5905 SE POWELL VALLEY RD | GRESHAM | OR | 97080 | 2018-03-13 | 695 | D | 1 | 0 | CI9L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review it was determined the facility did not follow up with information about the resident's need for a [MEDICAL CONDITION] (continuous positive airway pressure machine) or to provide documentation of the use of a [MEDICAL CONDITION] for 2 of 2 sampled residents (#s 1 and 3) reviewed for [MEDICAL CONDITION] usage. This placed the resident at risk for unmet needs. Findings include: 1. Resident 1 was admitted in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The local hospital transfer orders contained no physician's orders for a [MEDICAL CONDITION]. The facility's Admission Profile completed by Staff 8 (LPN) indicated the Admission Assessment information was obtained from the resident and local hospital records. The Admission Profile checked the box to indicate the resident used a [MEDICAL CONDITION]. There was no follow up about the usage of [MEDICAL CONDITION] by the facility staff. The 12/21/17 progress notes documented the resident had altered mental status and hands in the air trying to grab something. Resident 1 kept dozing off during conversations and had no fever. Vital signs were stable with low O2 sats of 79. The resident was placed on 2 liters of oxygen and O2 sats stayed between 82-86 percent. The local emergency medical transportation service was contacted and the resident was transported to the local hospital emergency department. The 12/26/17 progress notes documented the resident's caregiver called the facility about the concern the resident did not use a [MEDICAL CONDITION] while at the facility. Staff 12 (RNCM) reviewed the resident's discharge records and there was no orders for resident to have a [MEDICAL CONDITION]. Staff 12 called the local hospital to inquire about the [MEDICAL CONDITION] and the local hospital was to send the facility the [MEDICAL CONDITION] setting for physician's order for a [MEDICAL CONDITION] when she/he returned to the facility. On 3/7/18 at 10:36 AM Staff 8 (LPN) stated she could not remember completing the resident's Admission Profile. Staff 8 was asked if the box was checked on the Admission Profile and there was no physician's order for [MEDICAL CONDITION] or the [MEDICAL CONDITION] was in use. Staff 8 stated she would leave a nurse's note for the next shift nurse to review the need for a [MEDICAL CONDITION]. Staff 8 was informed there was no nurse's note for the next shift about the resident's need for [MEDICAL CONDITION]. On 3/8/18 at 4:24 PM Staff 1 (DNS) stated Staff 8 (LPN) could not remember Resident 1. Staff 1 stated the resident and caregiver did not tell the facility during the care conference or to the physician during facility visits. 2. Resident 3 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The 2/28/18 physician's orders documented the resident had a [MEDICAL CONDITION] at home. The local hospital discharge information documented the resident was bringing her/his [MEDICAL CONDITION] machine from home. The resident was on 2 liters of O2 through nasal cannula. The facility's 2/28/18 Admission Profile identified the resident used a [MEDICAL CONDITION] machine. The 3/1/18 physician notes documented the resident used her/his home [MEDICAL CONDITION] machine at night at home settings with no issues. The resident's vital signs to include O2 sats indicated the O2 sats of room air during the night shift of 3/2/18, 3/3/18, 3/4/18, 3/6/18, 3/7/18, 3/8/18 and 3/9/18. The (MONTH) and (MONTH) (YEAR) TAR included the direction to clean [MEDICAL CONDITION] mask with soap/water weekly and PRN. There was no documentation to monitor the resident's use of the [MEDICAL CONDITION]. On 3/12/18 at 12:24 Staff 1 (DNS) was asked to provide documentation Resident 3's [MEDICAL CONDITION] was used at night. No additional information was provided. | 2020-09-01 |