| 27 |
BENEFIS SENIOR SERVICES |
275012 |
2621 15TH AVE S |
GREAT FALLS |
MT |
59405 |
2019-07-11 |
880 |
E |
0 |
1 |
01HJ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to label and ensure the safe storage of oxygen and nebulizer therapy supplies for 1 (#29); and a staff member failed to wear a mask during caring for residents while experiencing cold/flu type symptoms, and had a stated history of pneumonia, for 42 sampled residents, in an attempt to prevent the spread of infection. Findings include: 1. During an observation on 7/8/19 at 3:00 p.m., resident #29's used nebulizer canister setup was attached to, and setting on the top of, the nebulizer machine located on the resident's bedside nightstand. The canister contained droplets of liquid. The resident stated she had last used the nebulizer the previous afternoon (7/7/19), and that the nurses always set it up for her to use. A 7-2 label was written on the side of the nebulizer mouthpiece, canister ring lid, and oxygen tubing. An unopened package of ipatroprium [MEDICATION NAME] sulfate vials was laying on the bedside nightstand beside the nebulizer machine. During an interview on 7/11/19 at 10:05 a.m., staff member Q stated CNAs and nursing staff learn about nebulizer use during onboarding activities as a skills check off (competency), and nebulizer use was also presented last year during facility skills days. She stated that facility staff followed facility policies related to nebulizer use. During an observation on 7/11/19 at 10:09 a.m., resident #29's nebulizer canister and tubing set was attached to and setting on the top of the nebulizer machine located on the resident's bedside nightstand. The canister was dry and contained no liquid or droplets. An unopened package of ipatroprium [MEDICATION NAME] sulfate vials was laying on the bedside nightstand beside the nebulizer machine. During an observation and interview on 7/11/19 at 10:19 a.m., staff member R stated resident #29 had declined the nebulizer treatment earlier that morning and staff member R was preparing the nebulizer treatment for [REDACTED]. Staff member R stated that nursing staff prepare the medication in the nebulizer canister setup and then resident #29 self-administers the nebulizer treatment and calls the nurse when she is done. Staff member R stated after the resident is done with the treatment, the nursing staff separate the canister pieces and rinse the pieces with saline. Staff member R stated the saline is kept in the cabinet in resident #29's bathroom, however staff member R was not able to locate a bottle of saline in the bathroom cabinet at the time of the interview. During an interview on 7/11/19 at 10:23 a.m., resident #29 stated the nurses neither clean the nebulizer canister setup nor do they set it out to dry in between uses; they just come in and add the medicine. Resident #29 stated once a week on Tuesdays the nurses change the tubing on the nebulizer, and on Thursdays they change the tubing on the concentrator. During an observation on 7/11/19 at 10:25 a.m., a blue plastic bag containing oxygen tubing and nasal cannula was hanging on the front of the oxygen concentrator, located in resident #29's bathroom. No date labeling was observed on the oxygen tubing and cannula. A review of the facility's policy titled BSS-Respiratory Therapy, showed Equipment is cleaned in the following manner: Nebulizers - To be rinsed and allowed to air dry after each use. 2. During an observation and interview on 7/8/19 at 1:52 p.m., staff member A was observed wearing a mask, which covered her nose and mouth. The staff member was coughing. Staff member A stated she did not want to get pneumonia again. She said she thought her coughing was from the air, and she was wearing the mask, to keep the air off and trying not to get the condition worse. During an observation on 7/8/19 at 5:11 p.m., staff member A was assisting residents with their meals, in the Memory Care dining room. The staff member was wearing a mask. At times she would turn and cough. During an observation on 7/9/19 at 8:54 a.m., staff member A was in the Memory Care kitchenette/dining room area. Staff member A was wearing a mask, covering her nose and mouth. Staff member A was coughing repeatedly. Staff member A was trying to assist residents with their meal. Staff member A was observed stepping away from the resident as she was coughing so hard. After trying again, staff member A walked back into the office, behind the nurse's station. During an observation and interview on 7/10/19 at 9:00 a.m., staff member A was in the Memory Care dining area\kitchenette area, and hall, assisting with residents with their breakfast, seating, and transfers. Staff member A was not wearing a mask. Staff member A's cough sounded deeper in her chest than the day prior. She had a difficult time controlling the cough, while assisting residents. Staff member A stated she did not need a mask, her cough had gone to her chest. Staff member A was observed assisting residents, in between coughing periods, until 10:30 a.m. Staff member A was coughing into her arm and was not observed sanitizing her hands between coughing periods. During an interview on 7/10/19 at 5:00 p.m., staff member DD stated staff member A should have been wearing a mask, per facility policy, relating to the cough and being around the residents. |
2020-09-01 |