cms_VT: 22
Data source: Big Local News · About: big-local-datasette
rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
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22 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2020-01-29 | 609 | D | 1 | 0 | GCF111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and confirmed by staff interview the facility failed to report to the State Licensing Agency, within the required time frame, injuries of an unknown source for 1 applicable resident, (Resident #1). This citation is a repeat that was cited on [DATE]. The findings include the following: Per medical record review for Resident #1, nurses' notes and an interaction communication form completed by the Registered Nurse (RN) on [DATE] at 07:00 identify a change in condition with a large bruise noted over the right eye, right scalp, forehead, in the morning. The RN evaluated the resident and identified the injuries as an unobserved event/injury. Per review of the RN documentation on the narrative event summary dated [DATE] at 7 AM, evidences (a small purple area on the right side of scalp, late Saturday evening, [DATE]. Today it is noted with a bruise above the right eye and scattered across his/her forehead and the bruise on his/her scalp is a lot larger in size). Circumstances of the event documented on the same narrative summary form evidences (possibilities may include resident bumping his/her head against the Hoyer (mechanical lift), and possibly when Licenses Nurse Aides (LNA's) were turning him/her, they may have bumped his/her head against the wall.) Per review of the nurses' notes dated [DATE] at 1500, the Licensed Practical Nurse (LPN) documents, (continues with forehead bruising and starting to spread to eyes. Has a bump on the right side of his/her head). Per phone interview on [DATE] at approximately 3:15 PM, confirmation was made by the RN that s/he did not make a report of injuries of unknown source to the licensing agency. S/he confirms that s/he has no understanding of how to make a report. S/he voiced that s/he reported the incident to the Director of Nurses (DNS). In-service documentation identifies that the RN has completed an in-service education at the facility on abuse reporting in (MONTH) 2019. Confirmation was made by the DNS on [DATE] at approximately 3:30 PM, that the injuries reported to him/her at the time of the notification were not described as documented. The facility did not suspect abuse, rather an unobserved event/injury. The facility policy titled Abuse Prohibition identifies that injuries of unknown source are defined as an injury with both of the following conditions: 1) The source of the injury was not observed by any person or the source of the injury could not be explained by the resident and 2) the injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular time. The Summary Report dated [DATE] confirms that both above conditions were met. Per review of the Chief Medical Examiner's preliminary report identifies that Resident #1 died on [DATE] with an immediate cause of death being generalized medical deconditioning. Other significant conditions are identified as [MEDICATION NAME] impact of the head identified as scalp and facial contusions. | 2020-09-01 |