Health inspection·July 29, 2021

F695 - RESPIRATORY CARE §483.25(i) The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subparts. The facility failed to provide respiratory care and services, consistent with physicians' orders and professional standards of care, for Resident 1, when the facility: a) failed to monitor Resident 1's oxygen saturation levels every shift to ensure oxygen saturation levels of at least 90%; b) failed to provide Resident 1 with oxygen per physician's order to maintain oxygen saturation levels of at least 90%, when Resident 1 had a documented oxygen saturation level of 78%; c) failed to provide Resident 1 with oxygen per physician's order when Resident 1 was found with labored breathing wearing a nasal cannula connected to an empty oxygen tank and had an oxygen saturation level of 83%; d) failed to ensure Resident 1 was administered oxygen according to professional standards of practice when Resident 1 was found with labored breathing and was administered oxygen at a rate of six liters per minute via a non-rebreather mask (a type of oxygen facemask attached to a reservoir oxygen bag connected to an external oxygen tank used to deliver higher concentrations of oxygen of at least 10 liters per minute) without a physician's order; and e) failed to provide Resident 1 with oxygen when Resident 1 was found wearing a non-rebreather oxygen mask with a deflated oxygen reservoir bag (indicating no oxygen was available) connected to an oxygen tank with the gauge indicating "0" (zero) oxygen. These failures placed Resident 1 at an imminent risk of death. On 7/29/20, at 10:30 a.m., an unannounced visit was conducted at the facility to investigate an outbreak of COVID-19 (a viral respiratory illness causing severe respiratory distress). A review of Resident 1's "Admission Record," printed on 7/29/20 at 1:32 p.m., indicated Resident 1 was admitted to the facility on 10/8/19. A review of the facility's census (a list of all residents in the facility and their room numbers), for 7/29/20, indicated Resident 1's room was in the facility's red area (for residents with COVID-19). During an interview on 7/29/20, at 10:40 a.m., the Administrator stated the facility had been divided into three color-coded areas: the red area housed residents who had a confirmed diagnosis of COVID-19, the yellow area was for residents who previously had a confirmed diagnosis of COVID-19 and since had tested negative for the virus but still presented with symptoms of COVID-19, and a green area for residents without COVID-19 and asymptomatic. COVID-19 is an infectious disease that affects the lungs and causes shortness of breath and difficulty breathing. Other symptoms include cough, fever, headache, loss of taste and smell, shaking and chills, sore throat and muscle pain. These symptoms range from mild to severe and can cause death. The risk for severe symptoms and death increases with age. The greatest risk of death is for people aged 85 or older. Treatment for COVID-19 includes the administration of supplemental oxygen to help with breathing and oxygenation. (District of Columbia Health Department. What is COVID? (available at https://coronavirus.dc.gov/page/what-covid-19) Centers for Disease Control and Prevention (CDC). Coronavirus Disease 2019 (COVID-19). (available at https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html) National Institutes of Health (NIH). COVID-19 Treatment Guidelines. (available at https://www.covid19treatmentguidelines.nih.gov/). During an observation on 7/29/20, at 1:15 p.m., Resident 1 was lying in bed in her room. Resident 1 had labored breathing and was wearing a nasal cannula connected to a portable oxygen tank with the oxygen level gauge in the tank indicating "0" (zero) oxygen. The state surveyor informed Licensed Nurse A who sent Certified Nursing Assistant (CNA) B to check on Resident 1. CNA B went into Resident 1's room and stated Resident 1's oxygen tank was empty. CNA B stated Resident 1 was supposed to be on oxygen. CNA B measured Resident 1's oxygen saturation using a pulse oximeter (a small device that slides over the fingertips and measures the level of oxygen in the blood) and stated Resident 1's oxygen saturation was 83%. Normal oxygen saturation levels measured by pulse oximetry are between 90-100%. Oxygen saturation levels lower than 90% indicate hypoxemia (abnormally low levels of oxygen in the blood). Oxygen saturation levels lower than 85% indicate severe hypoxemia. (Jubran, A. Pulse Oximetry. Critical Care (2015). (available at www.ncbi.nlm.nih.gov/pmc/articles/PMC4504215). Hypoxemia has been associated with death in patients diagnosed with COVID-19 (Mayo Clinic Proceedings, Association Between Hypoxemia and Mortality in Patients With COVID-19, June 2020; 95(6):1138-1147 / https://doi.org/10.1016/j.mayocp.2020.04.006 / www.mayoclinicproceedings.org) Professional standards of nursing practice indicate that residents receiving oxygen therapy require regular and frequent monitoring to ensure safe administration of oxygen. (Lippincott Manual of Nursing Practice, 9th Edition, Wolters, Kluwer Health, 2010, p. 245). During an interview on 7/29/20, at 1:40 p.m., the Director of Nursing (DON) stated Resident 1 had COVID-19 and confirmed Resident 1 was receiving supplemental oxygen per physician's orders. The DON was requested a copy of Resident 1's physician orders and provided "Order Summary Report", dated 7/29/20. A review of the "Order Summary Report", dated 7/29/20, indicated the following physician's order dated 1/14/20 for Resident 1: "Oxygen @ 2 liter/min [minutes] via Nasal Cannula continuous for O2 [oxygen] sat [saturation] below 90% on RA [room air]." During an observation on 7/29/20, at 1:50 p.m., Licensed Nurse C was in Resident 1's room checking Resident 1's vital signs. Licensed Nurse C stated Resident 1's oxygen saturation was 82%. Licensed Nurse C stated Resident 1 had run out of supplemental oxygen. A review of Resident 1's care plans (documents instructing staff on how to care for the resident), undated but provided by the facility during the survey, indicated no care plan or interventions for monitoring Resident 1's oxygen saturation or the functioning of oxygen equipment for Resident 1. During an interview on 7/29/20, at 3:40 p.m., the DON was asked for the facility's policy for monitoring residents receiving oxygen, including oxygen saturation. The DON stated the facility's policy was for residents to have a full set of vital signs taken once every shift (8 hours), which included oxygen saturation. The DON stated the oxygen saturation values were recorded in the residents' charts. During an interview on 7/29/20, at 3:40 p.m., the DON was asked for a copy of Resident 1's oxygen saturation measurements. The DON provided a copy of document titled "O2 Sats Summary" for Resident 1. A review of the "O2 Sats Summary" indicated the most recent oxygen saturation level for Resident 1 was dated two days prior, on 7/27/20, at 2:46 p.m., and indicated "90%" and "Oxygen via Nasal Cannula". The second most recent documented oxygen measurement saturation for Resident 1 was dated 7/27/20, at 2:30 p.m., and indicated "78%" and "Room Air" (not on oxygen). The third most recent documented oxygen measurement saturation for Resident 1 was dated more than a month before, on 6/9/20, at 10:18 p.m., and indicated "96%" and "Room Air". During an observation on 7/29/20, at 4:15 p.m., Resident 1 was lying in bed in her room. Resident 1 had labored breathing and was wearing a non-rebreather oxygen mask connected to a portable oxygen tank set at a rate of six liters per minute. During a concurrent interview, Licensed Nurse C was asked if Resident 1 had a physician's order for oxygen at six liters per minute via non-rebreather mask. Licensed Nurse C stated "no". Licensed Nurse C stated that another nurse, Licensed Nurse D, called Resident 1's physician who told Licensed Nurse D to "make Resident 1 comfortable", but stated no new oxygen orders were given. During an observation on 7/29/20, at 4:40 p.m., Resident 1 was lying in bed in her room. Resident 1 was wearing a non-rebreather oxygen mask with the oxygen reservoir bag deflated (indicating no oxygen was available) connected to a portable oxygen tank with the oxygen level gauge reading "0" (zero) oxygen. There were no staff in Resident 1's room. A non-rebreather oxygen mask uses an oxygen reservoir bag attached to the mask and connected to an oxygen source to deliver high concentrations of oxygen. Non-rebreather oxygen masks must be used with a high oxygen flowrate of at least 10 liters per minute and "must be used cautiously by experienced medical staff". (Hardavella, G., Karampinis, I., Frille, A.et all. Oxygen devices and delivery systems. Breath, September 2019, Volume 15, No. 3. (available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5532777) Baterman, N. T., & Leach, R. M. ABC of Oxygen - Acute oxygen therapy. British Medical Journal, September 1998 (available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6876135). According to professional standards of practice, the administration of oxygen therapy requires a physician's order: "Oxygen is a lifesaving treatment. It should be treated like any other drug; it should be prescribed in writing, with the required flow rate and the method of delivery clearly specified." Wong, W., & Elliott, M. The Use of Medical Orders in Acute Care Oxygen Therapy. The British Journal of Nursing. Volume 18 (2009). (available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1113909) The application of an oxygen mask without proper oxygen flow can result in death: "Never apply an oxygen mask on the patient without supplemental oxygen flowing; this results in the patient re-breathing their own CO2 [carbon dioxide - an asphyxiating gas], acidosis [high level of acid in the body], hypoxia [lack of oxygen in cells and tissues] and possible death." (Los Angeles Medical Services Agency - Los Angeles County. "Breathing Emergency - Oxygen Delivery", undated, available at www.lacounty.gov). The facility failed to provide respiratory care and services, consistent with physicians' orders and professional standards of care, for Resident 1, when the facility: a) failed to monitor Resident 1's oxygen saturation levels every shift to ensure oxygen saturation levels of at least 90%; b) failed to provide Resident 1 with oxygen per physician's order to maintain oxygen saturation levels of at least 90%, when Resident 1 had a documented oxygen saturation level of 78%; c) failed to provide Resident 1 with oxygen per physician's order when Resident 1 was found with labored breathing wearing a nasal cannula connected to an empty oxygen tank and had an oxygen saturation level of 83%; d) failed to ensure Resident 1 was administered oxygen according to professional standards of practice when Resident 1 was found with labored breathing and was administered oxygen at a rate of six liters per minute via a non-rebreather mask (a type of oxygen facemask attached to a reservoir oxygen bag connected to an external oxygen tank used to deliver higher concentrations of oxygen of at least 10 liters per minute) without a physician's order; and e) failed to provide Resident 1 with oxygen when Resident 1 was found wearing a non-rebreather oxygen mask with a deflated oxygen reservoir bag (indicating no oxygen was available) connected to an oxygen tank with the gauge indicating "0" (zero) oxygen. These failures placed Resident 1 at an imminent risk of death. The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.