Health inspection·September 1, 2022

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that a resident who required respiratory care, was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan, for one (Resident #75) of 10 residents receiving respiratory treatment, from a total of 13 residents in the sample. Residents Affected - Few The findings include: On 8/29/2022 at 10:16 a.m., Resident #75 was observed asleep in bed. Her nasal cannula was lying across her chest and an oxygen concentrator was observed at bedside. The concentrator was set to administer oxygen at a rate of 4 liters per minute (LPM). During a follow-up attempt to interview the resident at 1:11 p.m. the same day, she was again observed sleeping. The oxygen concentrator flow rate remained set at 4 LPM. On 8/30/2022 at 10:53 a.m., the resident was observed sitting up in bed with her nasal cannula in place. Her oxygen concentrator was still set to administer oxygen at 4 LPM. (Photographic evidence obtained) During another visit to the resident's room on 8/31/2022 at 11:07 a.m., her nasal cannula was in place. The oxygen concentrator remained set to administer oxygen at 4 LPM. On 8/31/2022 at 1:54 p.m., Resident #75 was observed resting in bed with her nasal cannula in place and her oxygen concentrator set to administer oxygen at 4 LPM. During an interview with Registered Nurse (RN) A on 8/31/2022 at 11:18 a.m., she confirmed the resident's oxygen was ordered at a flow rate of 2 LPM. She stated the certified nursing assistants (CNAs) were responsible for taking the residents' vital signs, and the nurses were responsible for adjusting the oxygen flow rates as needed. During the interview, RN A was asked to observe the oxygen for Resident #75. She went to the resident's room and confirmed that the resident's nasal cannula was in place. She further stated the concentrator was set to administer oxygen at 4 LPM. When she was asked about the flow rate, she stated it was titrated up to keep the resident's oxygen saturation (sats) above 92%. She was asked if there was an order for the titration to which she replied, At this point it's to keep her comfortable. RN A was unable to provide supporting physician's orders as requested. During an interview with CNA B on 8/31/2022 at 2:05 p.m., she stated she had been employed at this facility for nine years and Resident #75 was a total assist. She further stated the CNAs were responsible for ensuring that the residents' oxygen concentrators were set at the ordered flow rate. She stated the CNAs could consult the nurses or the residents' care plans for the oxygen orders. She Page 1 of 2 106077 106077 09/01/2022 Moosehaven 1701 Park Avenue Orange Park, FL 32073

F 0695 further stated the CNAs were responsible for filling the portable oxygen tanks. Level of Harm - Minimal harm or potential for actual harm During an interview with CNA C on 8/31/2022 at 2:15 p.m., she stated she had been employed at this facility for seven years and the CNAs were responsible for ensuring water was in the oxygen concentrator for Resident #75. They were also responsible for changing the oxygen tubing weekly. She stated the tubing for all residents receiving oxygen was changed every Sunday. When asked what Resident #75's oxygen flow rate should be set at, she did not answer. Instead, she stated, We can titrate it if her sats are less than 90%. We can adjust it between 2 and 4 (LPM) to get it back to the 90% or higher. When asked, she was unable to provide the orders for the oxygen flow rate or the orders for the titration. She stated the CNAs took vital signs daily and documented them on the vital sign sheet for all the residents. Once complete, the form went to the nurse. She stated the nurse then entered the information into the resident's electronic medical record once all the vitals were complete. Residents Affected - Few During an interview with Registered Nurse/Unit Manager D on 8/31/2022 at 2:22 p.m., she stated she was familiar with Resident #75. The resident was currently receiving Hospice services as her health was declining rapidly. She stated she spoke with RN A today regarding Resident #75. When she asked RN A about the oxygen for Resident #75, RN A advised her that the resident's sats were at 88% on 8/30/2022, so she increased the oxygen flow rate. RN D stated she reviewed the resident's records and observed that nursing charted they had increased the oxygen flow rate from 2 LPM to 3 LPM, and stated there was no order for that. She confirmed the current order for the oxygen level was 2 LPM, again stating there was no order to increase or decrease the oxygen flow rate for this resident. RN D stated she contacted the physician on the day of this interview for new orders. A review of Resident #75's medical record revealed a written physician's order for Oxygen @ 2L/NC PRN (oxygen at 2 LPM via nasal cannula as needed) to keep O2 sat (blood oxygen saturation) above 92% every shift. The order was signed and dated 8/24/2022. There were no additional orders in Resident #75's record related to her oxygen flow rate or titration. . 106077 Page 2 of 2