cms_NH: 68

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

This data as json, copyable

rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
68 DOVER CENTER FOR HEALTH & REHABILITATION 305018 307 PLAZA DRIVE DOVER NH 3820 2018-04-13 695 B 0 1 WGWA11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to provide and document that they maintained their schedule for changes in oxygen tubing for 4 residents in a standard survey sample of 22 residents. (Resident identifiers are #18, #23, #66 and #68.) Findings include: Resident #18 Observation on 4/11/18 at approximately 9:55 a.m. of Resident #18 revealed that Resident #18, who was on precautions for [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staph Aureus,) had oxygen tubing attached to an oxygen tank that Resident #18 was using and another oxygen tubing attached to an oxygen concentrator that they were not presently using. Neither of the two oxygen tubings had dates on them. Review on 4/13/18 of Resident #18's (MONTH) (YEAR) Treatment Administration Record revealed that there was no documentation that Resident #18's oxygen tubing was changed on 4/6/18, when it was due to be changed. The box for the nurses initials, documenting the change, was blank for 4/6/18. Review on 4/13/18 of Resident #18's (MONTH) (YEAR) Treatment Administration Record revealed that the last documented date that Resident #18's oxygen tubing was changed was on 3/27/18. Resident #23 Observation on 4/11/18 at approximately 9:40 a.m. of Resident #23 revealed an oxygen concentrator that was running next to Resident #23's bed as Resident #23 was laying in bed sleeping. The oxygen tubing had a piece of tape on the tubing that read 3/31/18. Review on 4/13/18 of Resident #23's Active Physician Orders revealed that Resident #23 had an order for [REDACTED]. Review on 4/13/18 of Resident #23's (MONTH) (YEAR) Medication Administration Record and Treatment Administration Record revealed that there was no documentation of changes to Resident #23's oxygen tubing. Resident #66 Observation on 4/11/18 at approximately 10:35 a.m. revealed that Resident #66 was using oxygen that was being administered through a nasal cannula. The oxygen tubing had tape attached to it that had the resident initials and room number on it, but no date. Review on 4/13/18 of Resident #66's Active Physician Orders revealed no physician order for [REDACTED].#66. Review on 4/13/18 of Resident #66's (MONTH) (YEAR) Medication Administration Record and Treatment Administration Record revealed that there was no documentation of changes to Resident #66's oxygen tubing. Resident #68 Observation on 4/11/18 at approximately 10:30 a.m. revealed that Resident #68 was using oxygen that was being administered through a nasal cannula. The oxygen tubing had tape attached to it that had the date of 3/29/18 on it. Review on 4/13/18 of Resident #68's (MONTH) (YEAR) Medication Administration Record and Treatment Administration Record revealed that there was no documentation of changes to Resident #68's oxygen tubing. Interview on 4/13/18 at approximately 12:00 p.m. with Staff A (Director of Nursing) revealed that there was no facility policy for care of oxygen and tubing, but stated that oxygen tubing was to be changed every week and the change was to be documented on the Medication Administration Record. Review on 4/13/18 of the facility's Performance Improvement Action Plan, dated 3/13/18, revealed the .Topic/Opportunity/Problem . was .Respiratory Equipment Oxygen tubing/infection control . The Plan identified that .oxygen tubing is not always signed off when changed on TAR (Treatment Administration Record) . The Systematic Changes that were put in place were .The staff nurse will sign off weekly on 11-7 shift and document on TAR .The unit managers will monitor weekly that tubing changes has (sic) been signed off per facility infection control practice . The Plan's follow up revealed .Mock survey completed by (Proper Noun) 4/3/18-4/4/18 and identified compliance with facility oxygen tubing change policy . 2020-09-01