Health inspection·August 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 medical record review, observation, staff interview, and policy review, the facility failed to ensure oxygen was administered as ordered. This affected three Residents (#11, #12, and #13) out of four residents reviewed for working oxygen concentrators. The census was 108. Residents Affected - Few Findings include: 1. Review of Resident #11's medical record revealed Resident #11 was admitted on [DATE] with diagnoses including congested heart failure, acute kidney failure, and chronic respiratory failure. Review of the Discharge Return Anticipated Minimum Data Set (MDS) assessment, dated 07/19/23, revealed Resident #11 had moderate cognitive deficits and required extensive assistance with activities of daily living (adl). Review of Resident #11's care plan, dated 07/13/23, revealed Resident #11 had oxygen therapy related to congestive heart failure and respiratory failure with interventions to monitor for respiratory distress and to give medicine as ordered by the physician. Review of Resident #11's physician order, dated 07/31/23, revealed an order for oxygen at two liters per minute via nasal cannula continuously due to shortness of breath. Observation on 08/02/23 at 9:37 A.M. during medication administration revealed Resident #11's oxygen concentrator was set to four liters per minute. Observation on 08/02/23 at 11:53 A.M. revealed Resident #11's oxygen concentrator was set to four liters per minute. Interview on 08/02/23 at 11:54 A.M. with Licensed Practical Nurse (LPN) #20 verified Resident #11's physician order was for two liters per minute and reported that Resident #11's oxygen concentrator was on the wrong setting. 2. Review of Resident #12's medical record revealed Resident #12 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure, sleep apnea, asthma, and respiratory disorders. Review of Resident #12's Annual MDS assessment, dated 07/11/23, revealed Resident #14 was cognitively intact and required extensive assistance with adls. Page 1 of 2 366432 366432 08/03/2023 Sanctuary Pointe Nursing & Rehabilitation Center 11501 Hamilton Avenue Cincinnati, OH 45231

F 0695 Level of Harm - Minimal harm or potential for actual harm Review of Resident #12's care plan, dated 03/16/18, revealed Resident #12 had oxygen therapy related to diagnosis with interventions which included oxygen settings: Resident #12 had oxygen via nasal cannula at three and half liters continuously. Keep oxygen saturation greater than 92%. Resident #12 used continuous positive airway pressure (CPAP) during night hours and call Resident #12's daughter if at any hour Resident #12 declines the oxygen mask. Residents Affected - Few Review of Resident #12's physician order, dated 08/30/22, revealed an order for Resident #12 to receive oxygen at three and a half liters per minute via nasal cannula continuously due to shortness of breath. Observation on 08/02/23 at 12:10 P.M. of Resident #12's oxygen concentrator revealed it was set to four and a half liters per minute. Interview on 08/02/23 at 12:18 P.M. with LPN #21 verified Resident #12's concentrator was set to four and a half liters per minute and should be set to three and a half liters per minute. 3. Review of Resident #13's medical record revealed Resident #13 was admitted on [DATE] with diagnoses including COPD, respiratory disorders, and cerebrovascular disease. Review of Resident #13's Significant Change MDS assessment, dated 07/19/23, revealed Resident #13 had severe cognitive impairment and required extensive assistance with adls. Review of Resident #13's care plan, dated 06/26/23, revealed Resident #13 had altered respiratory status and difficulty breathing related to episodes of shortness of breath with exertion or when lying flat. Resident #13 had continuous oxygen therapy and remained at risk for associated complications and fluctuations with care needs related to progression of COPD and respiratory disorders. Interventions included to provide oxygen as ordered. Review of Resident #13's physician order, dated 05/30/23, revealed an order for Resident #13 to receive continuous oxygen at two and a half liters per minute. Observation on 08/02/23 at 12:25 P.M. of Resident #13's oxygen concentrator revealed it was set to four liters per minute. Interview on 08/02/23 during observation with LPN #21 verified Resident #13's oxygen concentrator was set on four liters per minute and it should have been set to two and a half liters per minute. Review of the Oxygen Administration Policy, dated 02/28/20, revealed oxygen therapy can be initiated as a nursing judgement, if the resident's condition warrants, until notification to the physician is made and the order is obtained, otherwise, oxygen therapy is administered to the resident upon the written order of a licensed physician. This deficiency represents non-compliance investigated under Complaint Number OH00144713. 366432 Page 2 of 2