Health inspection·September 27, 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 observation, interview, and record review, the facility failed to provide a portable oxygen tank that was full for a resident. This applies to 1 of 3 residents (R1) reviewed for oxygen in a sample of 3. Residents Affected - Few The findings include: On 9/27/24 at 10:15 AM, surveyor and V2 (DON-Director of Nursing) went to R1's room. R1 was sitting in her wheelchair. At the back of her wheelchair, R1 had a portable oxygen tank that was connected to her nasal cannula. The dial was turned to 3 liters but it read empty. V2 removed the nasal cannula as instructed by the surveyor and put the nasal prongs near her wrist. Then, she passed it to surveyor who did the same thing. Both V2 and surveyor confirmed no air was able to be felt. R1 was asked if she felt any air and she said No! Surveyor asked R1 if she had any problems breathing or if she was in any type of distress. She stated no she was not. R1's oxygen saturation rate was 91%. On 9/27/24 at 10:18 AM, V2 stated that the tank should have been full or changed out. V2 also confirmed that when R1 was brought back to her room from the dining room, she should have been connected to her concentrator. On 9/27/24 at 10:21 AM, V4 (CNA-Certified Nursing Assistant) stated, I'm (R1)'s CNA today. She was on her concentrator last night. Then, I switched her to the portable oxygen tank and took her to the dining room so she can eat her breakfast. It was not empty then. Then I brought her back to her room. The oxygen tank was on yellow. I'm sorry. I should have changed it out. Did they bring a new oxygen tank for her? On 9/27/24 at 10:29 AM, V2 stated, (V3-Hospice Nurse) brought it to my attention that my staff wasn't using the portable oxygen concentrator that was provided by hospice for (R1) when she is in the dining room. Instead, they were using the portable oxygen tank. I inserviced my staff and made sure this was communicated to all the staff. I talked to V5 (LPN/Licensed Practical Nurse) and she told me the portable oxygen concentrator is charging, but it's not turning on. I told (V3) this but she said our staff is not charging it at night. We checked it today and it's not turning on. So, I have to tell hospice again to send a new one. On 9/24/24 at 1:48 PM, telephone interview was done with V3 (Hospice Nurse). V3 stated, The staff there are not using the portable oxygen concentrator when they are taking (R1) to the dining room. Instead, they are using the portable oxygen tank. Today and a couple of days ago, I saw the tank was turned off. I told them they have to get a new tank or (R1) is going to die. She is on hospice and has COPD. They are having problems keeping the tank full. Page 1 of 2 146067 146067 09/27/2024 Bria of Geneva 1101 East State Street Geneva, IL 60134

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R1's face sheet shows diagnoses of COPD (Chronic Obstructive Pulmonary Disease), Unspecified, cognitive communication deficit, unspecified atrial fibrillation, heart failure, schizophrenia, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Parkinson's disease without dyskinesia, without mention of fluctuations. R1's MDS (Minimum Data Set) dated 9/23/24 shows a BIMS (Brief Interview for Mental Status) score of 8, which means she is moderately impaired in cognition. R1's POS (Physician Order Sheet) for September 2024 shows the following orders: Admit to hospice with diagnosis of COPD (3/20/24), DNR (Do Not Resuscitate), Plug in portable oxygen at bedtime and apply during the day. Every day and night shift related to COPD. Plug in portable oxygen at bedtime and apply during the day. Progress notes show the following: On 8/20/24 at 6:10 AM (Medical Doctor's Note): [AGE] year old female admitted to facility on 2/24/23. Patient came in to ER (Emergency Room) due to acute hypercapnic and hypoxic respiratory failure. Felt to be due to COPD exacerbation. CT Chest shows extensive COPD with emphysema. 1. Severe COPD, oxygen deprivation. Appears compensated. Patient requires close monitoring, high risk for decompensating. On hospice care. On 9/17/24 at 8:38 AM (Nurse Practitioner Note): Oxygen down to 93% on 9/12, otherwise stable, occasionally forgets to apply oxygen cannula. Watch for respiratory status changes, any new symptoms. V3's (Hospice Nurse) Hospice Communication Log Note dated 9/26/24 shows: Routine visit. Patient SOB (Shortness of Breath) Oxygen tank turned off. This writer turned on and ensured patient comfortable breathing prior to leaving. R1's care plan (Undated) shows: (R1) has potential for difficulty in breathing related to COPD, Chronic Respiratory Failure, CHF (Congestive Heart Failure). Goal: (R1)'s respiratory symptoms will be managed through next review. Interventions: Administer oxygen as ordered. Hospice: (R1) is under the hospice care with terminal diagnosis of COPD. (R1) has oxygen therapy related to congestive heart failure, ineffective gas exchange, respiratory illness to COPD. Goal: The resident will have no signs or symptoms of poor oxygen absorption through the review date. Intervention: Give medication as ordered by physician. Monitor/document side effects and effectiveness. If the resident is allowed to eat, oxygen still must be give to the resident but in different manner (changing from mask to a nasal cannula). Return resident to usual oxygen delivery method after the meal. Oxygen inhalation at 2-5 LPM (Liters Per Minute) PRN (As Needed) related to SOB (Shortness of Breath) and/or respiratory distress. Facility's policy titled oxygen therapy (9/2022) shows the following: Oxygen therapy may be provided through various type of supply and delivery systems. Equipment may include the provision of oxygen through nasal cannulas, trans-tracheal oxygen catheters, oxygen canisters, cylinders or concentrators. Guideline: 1. Residents who require oxygen therapy will have a physician order in their medical record which includes amount of oxygen to be administered, route of administration and indication of use. 146067 Page 2 of 2