| 30 |
BURLINGTON HEALTH & REHAB |
475014 |
300 PEARL STREET |
BURLINGTON |
VT |
5401 |
2019-05-01 |
561 |
J |
1 |
0 |
IOQ211 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews with the resident and facility staff, the facility failed to promote and support the resident's choice (1 of 4 sampled, Resident #1) to participate in preferred activities and interact with members of the community, both inside and outside the facility, leading to an unsafe discharge. Findings include: Per record review, Resident #1 entered the facility on 6/27/18, following [MEDICAL CONDITION] (paralyzed in the lower body), caused by trauma. There was also a clear history of [MEDICAL CONDITION] among the admitting diagnoses. Resident #1 had a medical order allowing 1 beer per day. A note on 1/21/19 relates that Resident #1 was non-compliant with the 1 beer per day order, and thus the order was discontinued. Resident #1 had a written plan of care which outlined risk of adjustment issues related to isolation, difficulty accepting placement in center, loss of status and/or freedom associated with transition, loss of support network, coping with decline in overall health status, including functional decline. Additionally the care plan stated, It is important for me to go outside when the weather is good. Family and staff to assist outdoors, weather permitting. The facility could show no evidence that mental health or medically-related social services were engaged to assist Resident #1 with adjustment issues, or with abrupt withdrawal of alcohol use. On 4/18/19, the facility held a meeting with Resident #1 and informed him/her of their intent to enforce their requirement that all residents sign out and back in whenever leaving the facility. The facility had been allowing Resident #1 to leave and go off site to visit friends down the street. When Resident #1 went off premises on 4/19/19 without signing out, the facility called the police. This experience resulted in Resident #1 exhibiting increased efforts to assert independence and a right to autonomy. When questioned on 4/29/19 at 3:30 PM, Resident #1 stated, they let me go out and took it back; I can have a beer and a cheeseburger. In the wake of this further restriction, Resident #1 verbalized intent to leave the facility whenever s/he wanted, per Interdisciplinary Team (IDT) notes of 4/24/19. Resident #1 had been in discussions regarding autonomy and choices from January, 2019 through 4/24/19, and disagreed with restrictions the facility put in place regarding independence. There is no written evidence that the facility notified the ombudsman or issued a 30 day notice of discharge during the period prior to the 4/24/19 alleged AMA (against medical advice) discharge. Per interview with the Long Term Care ombudsman on 5/1/19 at 8:40 AM, the facility had never contacted him/her about this resident's issues surrounding independence or desire to leave the facility AMA until 4/25/19, the day after discharge. Due to the disagreement regarding rights to engage in activities outside the facility, the Administrator and other facility staff had Resident #1 sign an AMA document at 1:00 PM on 4/24/19. That afternoon, Resident #1 left the premises twice, and subsequently returned both times, indicating to the DNS s/he made a mistake. Per interview with a facility staff member who was a witness to the events during the second return to the facility, s/he stated that when the resident returned, the facility DNS (Director of Nursing Services) asserted the AMA status and refused re-admission to the facility. After asserting the AMA status and refusing re-entry to the resident despite clear needs surrounding care, the administration ordered a maintenance staff person to transport the resident to a hotel and paid for one night. Per observation at hospital at 3:30 PM on 4/29/19, and confirmed by hospital documents dated 4/25/19, Resident #1 deteriorated during the hotel stay and required emergency transport to hospital for treatment of [REDACTED]. |
2020-09-01 |