cms_OR: 93
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
93 | AVAMERE HEALTH SERVICES OF ROGUE VALLEY | 385024 | 625 STEVENS STREET | MEDFORD | OR | 97504 | 2019-06-20 | 695 | D | 1 | 0 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review it was determined the facility failed to ensure respiratory care was consistently provided and monitored for 2 of 6 sampled resident (#s 2 and 5) reviewed for respiratory care and accidents. This placed residents at risk for inadequate oxygen levels. Findings include: 1. Resident 2 admitted to the facility 12/2018 with [DIAGNOSES REDACTED]. Resident 2's medical record revealed a physician order [REDACTED]. The resident's 12/12/18 through 12/15/18 TAR revealed oxygen saturations were not checked on 12/13/18 on day or evening shift. A review of the resident Weights and Vitals Summary revealed the following: -From 12/16/18 through 12/27/18 no oxygen saturations were monitored (12 days). -On 12/28/18 oxygen saturations were only completed one time. -From 12/29/18 through 1/6/19 no oxygen saturations were monitored (nine days). On 5/22/19 at 8:52 AM Staff 34 (LPN) stated she recalled the resident utilized oxygen and had breathing difficulties. She indicated she would remind the resident to keep her nasal cannula in place. On 5/24/18 at 9:41 AM Staff 32 (CMA) stated she recalled the resident had a difficult time breathing and utilized oxygen. She stated they would have to remind the resident not to remove her/his nasal cannula. On 6/7/19 at 10:50 AM Staff 2 (DNS) stated any high risk resident should have oxygen saturations checked every shift. She acknowledged staff were not monitoring Resident 2 appropriately. 2. Resident 5 admitted to the facility 6/2012 with [DIAGNOSES REDACTED]. Resident 5's medical record revealed a physician order [REDACTED]. Resident 5's medical record revealed a physician order [REDACTED]. A review of the resident's 12/2018 and 1/2019 TARS revealed oxygen saturations were checked on 12/26/18 through 12/28/18 for three days, however no other information was located on the TARs regarding monitoring of Resident 5's oxygen saturations. A review of the resident Weights and Vitals Summary from 11/2018, 12/2018 through 1/2019 revealed the following: -From 11/1/18 through 11/5/18 no oxygen saturations were monitored (five days). -On 11/6, 11/9, 11/12, 11/13 and 11/26/18 oxygen checks saturation were only completed one time. -From 11/30/18 through 12/9/18 no oxygen saturations were monitored (10 days). -From 12/17/18 through 12/21/18 no oxygen saturations were monitored (five days). -From 1/1/19 through 1/3/19 no oxygen saturations were monitored (three days). -From 1/7/19 through 1/11/19 no oxygen saturations were monitored (five days). On 6/7/19 at 10:50 AM Staff 2 (DNS) stated any high risk resident should have oxygen saturations checked every shift. She acknowledged staff were not monitoring Resident 5 appropriately. | 2020-09-01 |