cms_SD: 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 | AVERA MARYHOUSE LONG TERM CARE | 435034 | 717 EAST DAKOTA | PIERRE | SD | 57501 | 2017-05-24 | 441 | E | 0 | 1 | 43OZ11 | Based on observation, interview, record review, and policy review, the provider failed to ensure nebulizer equipment had been cleaned according to the provider's policy for three of three residents (4, 18, and 19) that had received breathing treatments randomly observed. Findings include: 1a. Observation on 5/23/17 at 11:00 a.m. with resident 18 revealed: *The nebulizer equipment was fully assembled with a small amount of clear liquid in the medication chamber. *Medication was added to the medication chamber, without removing the small amount of clear liquid, by licensed practical nurse (LPN) F. b. Observation on 5/24/17 at 7:52 a.m. with resident 19 revealed: *The nebulizer mask and medication chamber was assembled and laying on the bedside stand. *There was a small amount of clear liquid in the chamber, prior to the medication being added to the chamber. *Medication was added by registered nurse (RN) E. c. Observation on 5/24/17 at 11:15 a.m. with resident 4 revealed: *His nebulizer was fully assembled with a small amount of a clear liquid in the medication chamber. *Medication was added to the chamber, without removing the small amount of clear liquid, by LPN F. d. Interview on 5/24/17 at 8:45 a.m. with LPN [NAME] revealed: *The night staff cleaned the nebulizer equipment every three days. *The equipment should have been replaced every month by night staff. -Including mouth piece or mask, medication chamber, and tubing. *These dates were noted on the treatment plan. Interview on 5/24/17 at 3:35 p.m. with the director of nursing (DON) revealed: *She would have expected the chamber and mouth piece or mask to have been disassembled and rinsed after every use. *Then should have been allowed to air-dry on a towel in the resident's room. Interview on 5/25/17 at 2:15 p.m. with CNA G revealed: *She had not seen the nebulizer equipment air drying in residents' rooms. *Usually they were placed on the bedside table fully assembled. Review of resident 4's medication administration record (MAR) revealed to clean the mask and nebulizer tubing every three days. Review of resident 18's MAR revealed to clean tubing and mouthpiece every three days. Review of resident 19's MAR revealed to soak nebulizer set up in dish soap, vinegar, and water, every 72 hours. Review of the provider's undated Nebulizer Cleaning policy revealed: *Rinse nebulizer mask with water every night after the last treatment. *Allow mask and medication component to air dry overnight. -Do not dry by hand as that could have left lint. *No mention of the tubing. | 2020-09-01 |