Health inspection·May 6, 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** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on record review, interview and facility policy review, the facility failed to ensure a Resident #88 had adequate supply of oxygen to attend an outside doctor's appointment. This affected one resident (#88) of three residents reviewed for respiratory services and had the potential to affect all residents that required oxygen. The facility identified 15 residents (#5, #6, #10, #15, #18, #32, #34, #41, #44, #76, #78, #81, #86, #87, and #88) who were dependent on oxygen. The facility census was 86. Findings include: Review of the closed medical record revealed Resident #88 was admitted to the facility on [DATE] and was discharged on 04/19/24. Pertinent diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease, urinary tract infection, anxiety, and obstructive uropathy. Significant orders included, change disposable oxygen equipment weekly, and oxygen at two liters via nasal cannula (a device to deliver oxygen through the nose) as needed to keep oxygen saturation above 92%. Review of the admission assessment dated [DATE] revealed Resident #88 was alert and oriented to person, place, and time. Resident #88 was noted to have oxygen on via nasal cannula at 3.4 liters per minute with an oxygen saturation rate of 98%. Review of the care plan dated 04/02/24 revealed Resident #88 had oxygen related to chronic obstructive pulmonary disease. Interventions included to give medications as ordered by the physician and monitor for signs of respiratory distress. A review of progress notes dated 03/29/24, 04/05/24 and 04/10/24 revealed Resident #88 to be on oxygen at three liters per minute via nasal cannula. Review of the medical record revealed Resident #88 had an appointment with the urologist on 04/11/24 at 10:30 A.M. On 05/06/24 at 9:40 A.M. an interview with Licensed Practical Nurse (LPN) # 205 revealed Resident #88 had a doctor's appointment on 04/11/24 at 10:30 A.M. Between 10:00 A.M. and 10:30 A.M. the facility received a phone call from Resident #88's daughter stating Resident #88's oxygen tank was empty. LPN #205 stated she immediately got an oxygen tank and delivered it to Resident #88 at his doctor's appointment, approximately 15 minutes away. LPN #205 stated Resident #88 was not in distress upon her arrival. Page 1 of 2 366491 366491 05/06/2024 Strongsville Healthcare and Rehabilitation 18936 Pearl Road Strongsville, OH 44136

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 05/06/24 at 9:59 A.M. an interview with the Administrator and Director of Nursing (DON) revealed Resident #88's oxygen was ordered as needed, and his daughter would run the oxygen despite his needs. On 04/11/24, the resident's daughter called from the doctor's office stating the resident's oxygen tank was empty. The doctor's office was called, and the resident was not in distress. Facility staff (LPN #205) took an oxygen tank to the doctor's office immediately which was about 15 minutes away, and the resident was not in distress upon her arrival. (The doctor's office had oxygen available per the resident's daughter). Review of the medical record revealed Resident #88 had no more complications related to oxygen through his discharge to another facility on 04/19/24 at the request of his daughter. A review of the policy titled; Leave of Absence, dated October 2022, revealed appropriate equipment as necessary will be sent with the resident during appointments. The deficient practice was corrected on 04/13/24 when the facility implemented the following corrective actions: • On 04/11/24, LPN #205 delivered an oxygen tank to Resident #88 at the doctor's office immediately after the facility was notified the oxygen tank ran out. • Beginning on 04/11/24 the Director of Nursing (DON) in-serviced nursing staff ensuring an appropriate supply of oxygen was sent with residents on leave of absences (LOA) and doctors' appointments. All nurses were in-serviced by 04/13/24. • Review of the LOA policy and education on 05/06/24 revealed all nursing staff had signed off on the in-service provided by the DON by 04/13/24. • Interviews with LPN #205 and LPN #313 on 05/06/24 between 9:40 A.M. and 2:45 P.M. revealed they had been in-serviced by the DON and were knowledgeable of the policy for ensuring residents going on LOA had all needed equipment, including oxygen. There have been no further incidents. This deficiency represents non-compliance investigated under Complaint Number OH00152982. 366491 Page 2 of 2