Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
of F328 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F328 is cited
0.0% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J—
K—
L—
Actual harm
G—
H—
I—
No harm, potential for more than minimal
D3100.0%
E—
F—
No harm, potential for minimal
A—
B—
C—
Every recorded F328 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F328 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
K · Immediate jeopardy, patternOctober 11, 2017
Complaint # (AR 611) was substantiated (all or in part) with these findings:
Based on record review and interview, the facility failed to ensure a ventilator-dependent resident was immediately assessed and that manual respiratory support was provided with an ambu-bag during an approximately 2 to 2.5-minute period when the ventilator was malfunctioning, to prevent [MEDICAL CONDITION] and related complications, and failed to accurately communicate the incident to emergency medical personnel to facilitate appropriate treatment for 1 (Resident #1) of 5 (Residents #,[DATE]) case mix residents who were ventilator-dependent. …
Based on interview, and record review the facility failed to immediately answer a ventilator machine alarm for one of three residents (R4) reviewed for specialty care on the sample of six. This failure resulted in R4 requiring cardio-pulmonary resuscitation.
Findings include:
R4's History and Physical dated [DATE] documents R4 has diagnoses' of [MEDICAL CONDITION] with Hypercapnia, Acute and Chronic [MEDICAL CONDITIONS], Ventilator Dependant, and [MEDICAL CONDITION].
Nursing notes written by E3 Registered Nurse, dated [DATE] at 7:30 P.M. documents, (R4) was in bed sitting with head of bed up at (6:00 AM) when writer administered morning medications. (R4) alert and oriented with (complaints of) back pain. (As needed) [MEDICATION NAME] administered per (physician) order. …
D · No harm, potential for more than minimal, isolatedJune 19, 2018
Based on observation. interview and record review, the facility did not perform [MEDICAL CONDITION] (an artificial opening through the neck into the windpipe to assist with breathing) care properly for one Resident (4).
As a result, Resident 4 had the potential to develop an infection.
Findings:
Resident 4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].
On 4/11/17 at 8 A.M. an observation of [MEDICAL CONDITION] care for Resident 4 was conducted with licensed nurse (LN) 3. LN 3 stated he had not been using sterile Q-tips (cotton applicators) for about 2 weeks. LN 3 stated: We have a new supplier and they brought regular (not sterile) Q-tips.
On 4/11/17 at 9:30 A.M., an interview was conducted with the director of nursing (DON). …
B · No harm, potential for minimal, patternNovember 7, 2017
Based on observations and interview the facility failed to ensure respiratory services related to [MEDICAL CONDITION] care were consistent with professional standards for 3 of 19 sample residents (#4, 9 & 17).
Findings included:
On 11/07/17 between 2:30 PM and 2:42 PM, observations of Resident #4, 9 & 17 were conducted with Respiratory Therapy staff. The emergency [MEDICAL CONDITION] supplies at the bedside did not contain an extra [MEDICAL CONDITION] a size smaller.
At 2:30 PM, Staff D instructed respiratory therapy staff to verify residents' bedside emergency supplies.
WAC Reference 388-97-1060(3)
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