| 59 |
MINOT HEALTH AND REHAB, LLC |
355031 |
600 S MAIN ST |
MINOT |
ND |
58701 |
2019-06-11 |
695 |
D |
1 |
0 |
HFFF11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on information provided by the complainants, observation, record review, review of professional reference, and staff interview, the facility failed to provide the necessary care and services for 2 of 3 residents (Resident #1 and #13) receiving oxygen. Failure to provide oxygen as ordered has the potential for residents to experience complications related to inadequate oxygen saturation levels. Findings include: Information provided by the complainants indicated nursing staff failed to ensure oxygen was administered per physician's order. Review of the facility policy titled Oxygen Administration occurred on 06/10/19. This policy, revised (MONTH) (YEAR), stated, . Validate physician orders for oxygen and set liter flow according to physician order. Berman and Synder, S., Kozier & Erb's Fundamentals of Nursing Concepts, Process, and Practice, 9th ed., Pearson Education, Inc., New Jersey, page 1397, stated, OXYGEN THERAPY . Like any medication, oxygen is not completely harmless to the client. Clients receive an inadequate amount or an excessive amount of oxygen and both can lead to a decline in the client's condition. An inadequate amount of oxygen ([MEDICAL CONDITION]) will lead to cell death, and if left untreated can ultimately lead to death. - Review of Residents #1's medical record occurred on all days of survey. A physician's order stated, . Oxygen at 2 L/M (liters per minute) to maintain O2 (oxygen) sats (saturations) >90%. Check each shift. Observation on 06/04/19 at 11:05 a.m., and 06/05/19 at 10:08 a.m., showed Resident #1 wearing a nasal cannula attached to an oxygen concentrator set at 1 liter per minute. The facility failed to consistently provide Resident #1 oxygen at the ordered concentration per nasal cannula. - Review of Resident #13's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. A current physician's order stated, Oxygen at 2L (liters) to keep sats greater than 90% prn as needed . Review of Resident #13's oxygen sats since (MONTH) 2019 showed resident oxygen sat levels remained above 90% daily with oxygen applied. The current care plan stated, . Has/At risk for respiratory impairment related to: history of recurrent pneumonia . Oxygen per MD orders . All observations during survey showed Resident #13 with oxygen on continuously at 2L. During an interview on 06/06/19 at 10:00 a.m., an administrative nurse (#5) stated Resident #13's family requests oxygen on continuously and confirmed the facility should obtain a continuous oxygen order. |
2020-09-01 |