Health inspection·August 24, 2023

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, medical record review, and interviews, the facility failed to ensure that one (Resident #25) of ten residents receiving oxygen, from a total sample of 27 residents, received oxygen at the correct settings as ordered by the physician. Residents Affected - Few The findings include: An observation was made of Resident #25 on 8/22/23 at 9:00 a.m. in her room. She was lying in bed with oxygen infusing at 3 liters per minute via an oxygen concentrator. (Photographic evidence obtained) On 8/22/23 at 3:01 p.m., Resident # 25 was observed sitting in a wheelchair at bedside with oxygen flowing at a rate of 3 liters per minute via nasal cannula via the oxygen concentrator. Resident #25 did not know what the flow rate setting should have been. (Photographic evidence obtained) An observation was made of Resident #25 on 8/23/23 at 12:25 p.m. receiving a.m. care. Oxygen was observed infusing at 3 Liters per minute via nasal cannula. (Photographic evidence obtained) An observation was made of Resident #25 on 8/23/23 at 1:26 p.m. sitting up in a wheelchair at bedside. She had just finished her lunch. Oxygen was infusing at 3 Liters per minute via nasal cannula. (Photographic evidence obtained) A review of Resident #25's electronic medical record revealed that she was admitted on [DATE] with diagnoses including congestive heart failure, atrial fibrillation and neoplasm of the uterus. A physician's order dated 7/27/23, noted oxygen continuous at 2 liters per minute via nasal cannula in the medical record. A review of the Medication Administration Record (MAR) for August 2023, revealed that the physician's order dated 7/27/23 for oxygen continuous at 2 Liters per minute via nasal cannula, was signed off daily as having been administered per the order. The care plan, updated on 7/28/23, noted the resident was at risk for complications related to respiratory disease, shortness of breath, and congestive heart failure. The intervention was to administer oxygen as ordered by the resident's physician. An interview was conducted with Registered Nurse (RN) A at 1:28 p.m. on 8/23/23. The RN was asked how many Liters of oxygen Resident #25 was receiving, and she stated she needed to review the resident's physician's orders. She reviewed the orders and reported that oxygen should be infusing at 2 Liters per minute. RN A was accompanied to Resident #25's room to check the resident's oxygen flow rate. RN A confirmed that the resident's oxygen was set at 3 Liters per minute and she changed the setting to 2 Liters per minute. Page 1 of 2 105915 105915 08/24/2023 Solaris Healthcare Daytona 550 National Healthcare Drive Daytona Beach, FL 32114

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted with the Director of Nursing (DON) on 8/23/23 at 1:45 p.m. The DON reported continuous oxygen settings should be checked every shift by the assigned nurse. A review of the facility's policy for Oxygen (revised on 1/25/23) revealed the following: Steps in setting up the oxygen: Number 2: Turn on oxygen. Start flow at ordered rate. Under step #4: Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. . 105915 Page 2 of 2