Facility Evaluation Report

Licensing Program Analyst (LPA) Javina George made an unannounced case management deficiencies visit in correlation to complaint control number 18-AS-20200513115313 . The following deficiencies are being cited:

Neglect/lack of care and supervision-staff failed to meet resident's needs:

Resident #1 (R1) was prescribed to use both a nebulizer machine and oxygen concentrator. During dinner R1 was seated at the bar area and observed by Staff #2 (S2) described R1 as “bluish, coughing choking”. S2 helped R1 back to their room, and informed S1 about R1s condition. S1 responded to R1s room to administer oxygen, which was later confirmed to have been the nebulizer. Staff 3 and 4 were making rounds when they observed that R1 was hooked up to the wrong machine. R1 admitted that there was a “mix up with the machine”. R1 also stated the mix up was with the “wires” and “the hose”. S1 stated that the “wires” and “the hose” were tangled and that it was the first time attempting to connect R1 up to the oxygen machine and must have switched it. S1 admitted to picking up the nebulizer machine and setting it on the table. “I remember panicking”. S1 confirmed that she had intended to put R1 on oxygen. S3 and S4 properly connected R1 to the oxygen machine. Hospice was then called to come out to the facility due to R1 having a “change in condition.” It was also determined that S1 failed to notify facility staff and the hospice agency of the mishap. S1 has received verbal and written counseling and the facility provided all staff training on the difference between an oxygen and nebulizer treatment.

In addition the incident described/noted above, the facility failed to follow reporting requirements. The information about the incident of R1 not being hooked up to their oxygen machine as needed, but to their nebulizer was withheld as it was not reported. A deficiency is being cited as the facility did not report the incident as required.

An exit interview was conducted and a copy of this report and appeal rights were provided to Lisa Hunt, Executive Director.