Health inspection·October 3, 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 observation, interview, record review and policy review the facility failed to provide oxygen as ordered by the physician. This affected two Residents (#2 and #26) of three reviewed for oxygen. The facility census was 86. Residents Affected - Few Findings included: 1. Review of Resident #2's medical record revealed she was admitted to the facility on [DATE] with diagnoses including multiple myeloma not having achieved remission, generalized muscle weakness, shortness of breath, acute respiratory failure with hypoxia, and pleural effusion in other conditions classified elsewhere. Review of Resident #2's admission Minimum Data Set (MDS) 3.0 assessment, dated 08/18/23, revealed she was cognitively intact and had an active diagnosis of respiratory failure. Further review revealed she received oxygen therapy while not a resident and while a resident. Review of Resident #2's physician order dated, 08/29/23, identified she was to have continuous oxygen at two liters/minute per nasal cannula. The staff were to check placement and record oxygen saturation every shift. Observation on 10/02/23 at 10:05 A.M. of Resident #2 with oxygen running at four liters/minute via a nasal cannula. The date on the tubing is 09/25/23. Observation on 10/02/23 at 11:05 A.M. of Resident #2 with oxygen running at four liters/minute via a nasal cannula. The date on the tubing is 09/25/23. Observation on 10/02/23 at 11:21 A.M. of Resident #2 with oxygen running at four liters/minute via a nasal cannula with Licensed Practical Nurse (LPN) #193. LPN #193 verified Resident #2's oxygen was running at four liters/minute via a nasal cannula. Interview on 10/02/23 at 11:27 A.M. with LPN #193 verified Resident #2's oxygen was not running at the correct dosage, and it should be running at two liters/minute via her nasal cannula. 2. Review of Resident #26's medical record revealed she was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), unspecified, dependence on supplemental oxygen, and shortness of breath. Review of Resident #26's significant change MDS 3.0 assessment, dated 09/14/23, revealed she was Page 1 of 2 365612 365612 10/03/2023 Summit Acres Nursing Home 44565 Sunset Road Caldwell, OH 43724

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cognitively intact and had an active diagnosis of asthma, COPD, or chronic lung disease. Further review revealed she received oxygen therapy while a resident. Review of Resident #26's physician order, dated 04/28/23, identified she was to have continuous oxygen at four liters/minute per nasal cannula. The staff were to check placement and record oxygen saturation every shift. Observation on 10/02/23 at 10:03 A.M. of Resident #26 with oxygen running at five liters/minute via a nasal cannula. There was no date on the tubing. Observation on 10/02/23 at 11:03 A.M. of Resident #26 with oxygen running at five liters/minute via a nasal cannula. There was no date on the tubing. Observation on 10/02/23 at 11:18 A.M. of Resident #26 with oxygen running at five liters/minute via a nasal cannula with Licensed Practical Nurse (LPN) #193. LPN #193 verified Resident #26's oxygen was running at five liters/minute via a nasal cannula. An interview at the time with LPN #193 revealed the oxygen tubing is changed weekly by the company who takes care of their oxygen. Interview on 10/02/23 at 11:25 A.M. with LPN #193 verified Resident #26's oxygen was not running at the correct dosage, and it should be running at four liters/minute via her nasal cannula. She also verified Resident #26 had an active diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and residents with COPD's drive to breath is a lower oxygen level. She verified it was detrimental for a COPD resident to be on oxygen at five liters/minute. Interview on 10/02/23 at 12:00 P.M. with Resident #26 revealed she turned her oxygen up to five liters/minute on 10/01/23 and no nursing staff had looked at her machine to see what her oxygen was running at since she changed it. Interview on 10/02/23 at 12:35 P.M. with the Director of Nursing verified residents' oxygen should run as ordered by the physician and residents who have a COPD diagnosis should not have oxygen running at five liters/minute per nasal cannula. Review of facility policy titled, O2 - Facility Utilization, undated, revealed it was the facility policy that O2 will be provided to Residents with a physician order. Further review revealed the facility will assess the clinical need of the resident and obtain a physician order. This deficiency represents non-compliance investigated under Complaint Number OH00146607. 365612 Page 2 of 2