Health inspection·November 21, 2024

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, facility document review, and the facility policy and procedure review, the facility failed to ensure that residents who needed respiratory care, were provided such care, consistent with professional standards of practice, for one (Resident #95) of four residents reviewed for respiratory care, in a total survey sample of 28 residents. Resident #95 did not receive oxygen at the flow rate ordered by his physician. Residents Affected - Few The findings include: On 11/18/24 at 1:10 PM, Resident #95 was observed fully dressed, sitting in his wheelchair inside his doorway communicating with Maintenance Director A in Spanish. His room was approached and the resident's nasal cannula was observed on the floor next to his wheelchair. Maintenance Director A advised Licensed Practical Nurse (LPN) B that Resident #95's nasal cannula was on the floor. The Director of Nursing (DON) also advised LPN B that Resident #95 needed an oxygen tank for his wheelchair. The oxygen flow rate on the concentrator was set between 1.5 and 2.0 Liters per minute (L/min). (Photographic evidence obtained) On 11/19/24 at 8:34 AM, Resident #95 was not wearing his nasal cannula and the oxygen flow rate on his wheelchair oxygen tank was set at 2 L/min. (Photographic evidence obtained) A review of the resident's active Physician's Orders revealed the following: Oxygen at 3 L/min via nasal cannula, continuously every morning and at bedtime for oxygen management. (Dated 10/1/24) Change oxygen tubing weekly. Label each component with date and initials every night shift every Sunday for infection control. Change humidifier and label. (Dated 11/17/24). (Copy obtained) A review of the resident's medical record revealed an admission date of 10/1/24 with a previous admission on [DATE]. Resident #95's diagnoses included acute respiratory failure with hypoxia; shortness of breath, other pneumonia, unspecified organism, a need for assistance with personal care; adjustment disorder with anxiety; and anxiety disorder. A review of the resident's Quarterly Minimum Data Set (MDS) assessment, dated 10/4/24, revealed that the resident was independent with eating and required oxygen therapy. A review of the resident's active care plan revealed that focuses and goals included altered or potential for altered respiratory status related to shortness of breath. Interventions included to Page 1 of 2 105692 105692 11/21/2024 Vivo Healthcare Orange Park 570 Wells Rd Orange Park, FL 32073

F 0695 anticipate and meet the resident's needs and provide oxygen as ordered. Level of Harm - Minimal harm or potential for actual harm On 11/20/24 at 4:25 PM, LPN C confirmed that Resident #95's oxygen flow rate order was for 3L/min. She stated the oxygen flow rate should be set at 3L/min. All staff provided ongoing monitoring of the resident's oxygen therapy. Nursing was responsible for assuring that the resident was receiving the correct oxygen flow rate per the physician's order. Correct oxygen flow rate settings were identified by checking the orders. Correct settings were communicated from one nurse to the next through nursing report sheets and reviewing the MAR. Resident #95 did not refuse oxygen therapy, though he would sometimes take the nasal cannula off. Residents Affected - Few On 11/20/24 at 4:34 PM, the DON confirmed that correct oxygen flow rate settings were found in the resident's physician's orders. A review of the facility's policy and procedure titled Oxygen Administration (implemented on 03/2024), revealed: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. A review of the facility's policy and procedure titled Medication Administration (implemented on 03/24/23), revealed: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 14. Administer medication as ordered in accordance with manufacturer specifications. (copy obtained) . 105692 Page 2 of 2