cms_AZ: 10
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10 | THE TERRACES OF PHOENIX | 35003 | 7550 NORTH 16TH STREET | PHOENIX | AZ | 85020 | 2019-10-17 | 695 | D | 0 | 1 | EJUZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews, and policy review, the facility failed to ensure oxygen tubing for one sampled resident (#8) was changed as ordered and stored consistent with professional standards of practice. The deficient practice could result in respiratory complications and infection. Findings include: Resident #8 was admitted to the facility on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The Treatment Administration Record (TAR) for (MONTH) 2019 revealed the oxygen tubing was changed on (MONTH) 6 and again on (MONTH) 13. During an observation conducted of the resident's room on (MONTH) 15, 2019 at 9:56 a.m., the resident was not observed using oxygen. The oxygen concentrator was on and in the bathroom shower. The tubing was connected to the concentrator and part of the tubing was lying on the floor of the shower. Another part of the tubing was looped around the grab bars next to the toilet. The tubing extended out of the bathroom, into the resident's room and was wrapped around the table next to the resident who was sitting in a chair. The tubing on the concentrator had a label with the date (MONTH) 12 on it. The nasal cannula had a separate label that had the date (MONTH) 5 on it. An interview was conducted with the resident immediately following this observation. The resident stated the oxygen concentrator was moved into the shower that morning to make room for staff to clean up an accident and that no one noticed the concentrator needed to be moved back into her room. Resident #8 stated that she does not know when the staff changes the oxygen tubing. Another observation was conducted of the resident's room was on (MONTH) 16, 2019 at 1:25 p.m. The oxygen concentrator was observed in the bathroom, but was no longer in the shower. Part of the tubing from the concentrator was wrapped around the grab bars next to the resident's toilet, and part of it was coming out of the bathroom and lying on the floor next to the resident's bed. The label on the tubing was dated (MONTH) 12. The tubing for the nasal cannula was on the table next to the resident's bed, and the label was dated (MONTH) 5. An observation was conducted of resident #8's room on (MONTH) 17 at 10:20 a.m. The oxygen concentrator was observed in the resident's bathroom. The tubing was wrapped around the grab bars behind and next to the toilet, coming out of the bathroom and lying on the table next to the resident's bed. The label on the concentrator tubing contained the date 12. The label on the nasal cannula tubing contained the date (MONTH) 19. An interview was conducted with a Registered Nurse supervisor (RN/staff #102) on (MONTH) 16, 2019 at 2:59 p.m. The RN stated the night shift staff changes the oxygen tubing for all residents who have that order. Staff #102 stated the tubing should be changed at least weekly, and should be done on schedule. She stated once the tubing has been changed and labeled it will documented on the TAR. The RN stated that the night nurse may have missed changing resident #8's oxygen tubing. She also stated that it should not have been documented as done on the TAR if it was not done. The RN stated that the date on the labels is the date the tubing is supposed to be changed. The supervisor stated that she did not want to observe the tubing at this time, and that she would ask the night nurse what happened when she reported for work. An interview was conducted with the Director of Nursing (DON/staff #4) on (MONTH) 17, 2019 at 10:38 a.m. The DON stated all oxygen tubing should be changed weekly and as ordered. She also stated the labels on the tubing should be updated when the tubing is changed, and documentation on the TAR should reflect the task was done. She stated it was brought to her attention yesterday that resident #8's oxygen tubing had not been changed as ordered. She stated the tubing was changed last night (October 16, 2019). The DON stated she did not know why it was documented on the TAR that the oxygen tubing was changed when the labels on the tubing did not reflect it was changed. She stated that the date on the tubing should be the date the tubing was last changed. During an interview conducted with a Certified Nursing Assistant (CNA/staff #68) on (MONTH) 17, 2019 at 12:58 p.m., the CNA stated the oxygen tubing should be kept in a bag in the resident's room when not in use. Another interview was conducted with the DON on (MONTH) 17, 2019 at 1:05 p.m. She stated that all oxygen tubing should be kept in a black antimicrobial bag when not in use. She stated this bag should be stored somewhere near the concentrator. She also said they change the bags every 30 days to prevent infections. The DON stated the tubing should never be stored on the floor. The DON also indicated that she was not aware of how resident #8's oxygen tubing was being stored. The facility's policy and procedure regarding Respiratory Therapy Prevention of Infection revised (MONTH) 2011 revealed the purpose of the procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment among residents and staff. The policy instructs to change the oxygen cannula and tubing every seven days or as needed, and to keep the oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use. | 2020-09-01 |