cms_AK: 27
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 27 | KETCHIKAN MED CTR NEW HORIZONS TRANSITIONAL CARE | 25010 | 3100 TONGASS AVENUE | KETCHIKAN | AK | 99901 | 2019-08-23 | 684 | D | 0 | 1 | 0OWF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to provide treatment in accordance with professional standards for 1 (#10) resident out of 14 sampled residents. Specifically, the resident was receiving oxygen without a physician's order. This failed practice placed the resident at risk for receiving less than optimal care and incorrect treatments. Findings: Record review from 8/19-23/19 revealed Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the admission MDS (Minimum Data Set, a federally required nursing assessment), assessment dated [DATE] revealed the Resident did not use oxygen therapy. Review of Resident #10's H&P (history and physical), dated 6/17/19, revealed Continue respiratory medications .oxygen as needed. An observation on 8/19/19 at 4:00 pm revealed the Resident lying in bed with his/her eyes closed and wearing oxygen via nasal cannula (oxygen delivery system tubing). During an interview on 8/20/19 at 9:45 am, Resident #10 stated he/she wore oxygen mostly while he/she slept. The oxygen in the Resident's room was turned on at 3 l/min (liter per minute of oxygen flow). The nasal cannula was positioned next to the Resident in the Resident's bed. During an interview on 8/22/19 at 8:40 am, Licensed Nurse (LN) # 4 stated Resident #10 used oxygen as needed. LN #4 further stated that the Resident would use the oxygen when the Resident had chest pain. During an interview on 8/22/19 at 12:40 pm, LN # 2 stated Resident #10 used oxygen as needed. He/she would check the Resident's oxygen saturation (a noninvasive test to see how much oxygen is in the blood stream) and would provide the Resident oxygen as needed. A review of Resident #10's most recent physician's orders with LN # 2 revealed no physician order for [REDACTED].# 2 further stated that he/she would call the physician for the oxygen order. During an interview on 8/22/19 at 1:44 pm, LN # 4 stated he/she did not know if a physician order was required for oxygen use of 2 l/min or less, that oxygen use may have been at the LN discretion. A copy of the facility's policy for oxygen was requested of LN #4 at this time and was not provided by the close of the survey. A review of Resident #10's care plan Multidisciplinary Problems (Active), not dated, revealed no interventions for oxygen therapy. During an interview on 8/22/19 at 1:50 pm, the MDS Coordinator stated that oxygen therapy should be documented on the Resident's care plan. The MDS Coordinator further stated that a physician's order for oxygen would have triggered him/her to add oxygen to the care plan. According to Nurses Service Organization, accessed 9/9/19 at https://www.nso.com/Learning/Artifacts/Articles/Administer-meds-without-a-doctor-s-order-Proceed> Registered nurses generally should administer medications only with a physician's order .Giving a patient medication .without a physician's or nurse practitioner's knowledge has many risks. Most important, the medication could be contraindicated, even if it seems innocuous. | 2020-09-01 |