cms_VT: 35
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 35 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2019-05-01 | 626 | J | 1 | 0 | IOQ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff and resident interviews, the facility failed to permit return to the facility after a therapeutic leave for 1 of 4 residents in the sample (Resident #1). Findings include: Per record review, staff and resident interviews, Resident #1 returned to the facility 4/24/19 at least twice after having been considered discharged against medical advice (AMA) by the facility (signature on 4/24/19 at 1:00 PM, per AMA document). The facility thought the resident was leaving the building to go to a friend's to live, but took no steps to ensure care/services at that discharge location, nor confirm that as an option. At 3:30-4 PM, Resident #1 was observed in the building on the 4th floor, per interviews with the nurse unit manager (4/29/19 at 12:05 PM), the Nurse Practitioner (4/30/19 9:35 AM), as well as by both the Administrator and Director of Nursing/DNS (4/30/19 at 9:00 AM). Per facility records, and these interviews, Resident #1 again left the premises, allegedly going to the hospital (where he presented as homeless needing housing and was turned away) and returned again to the facility at approximately 5:00 PM, clearly in need of care, indicating to the DNS s/he made a mistake. During the above interviews, witnesses placed Resident #1 in the building again, meeting in the ground floor conference room with administrator, DNS, Assistant DNS, and Business Manager regarding funds. The Assistant DNS was confirmed having dialed the phone for Resident #1 to talk with his/her daughter and others because the resident could not independently dial the phone due to hand tremors. At approximately 5:30 PM on 4/24/19, the Occupational Therapist (OT) confirmed having talked to Resident #1 from a window, as s/he was outside near the rear of the building, and asked Resident #1 to meet him/her at the entrance. Confirmed during this interview on 4/29/19 at 12:45 PM, the OT described that s/he went to the DNS and advised that Resident #1 was not safe and capable of living alone in the community. The DNS stated clearly to the OT, per this interview, that Resident #1 was AMA and not to receive medical care nor allowed to stay at the facility that night. S/he stated that when the resident returned, the facility DNS (Director of Nursing Services) asserted the AMA status to the resident and refused re-admission to the facility. When interviewed at the hospital on [DATE] at 3:30 PM, the resident said s/he did not specifically ask for re-admission because the DNS told me (s/he) would call the cops; they did that before so I knew they would. The facility had called the police on 4/19/19 and allowed return to the facility after Resident #1 left the premises in a perceived elopement (notes of 4/19/19, confirmed by administrator and DNS 4/30/19 at 9:00 AM). The facility then arranged for the one-night stay at a hotel for the night of 4/24/19 instead of readmitting the resident who had extensive care needs, and had a maintenance person transport the resident, with plastic bags of clothing, belongings, and medications, and a list of area healthcare providers, along with the electric wheelchair. The facility did not permit the resident to re-admit to the facility after a therapeutic leave and mis-understanding of the AMA discharge due to possible altered mental status and brewing infection. After spending approximately 24 hours in the hotel, and having 3 emergency 911 responses for care and welfare checks, Resident #1 was admitted to the hospital on [DATE]. Hospital records showed a multi-drug resistant urinary tract infection which represented substantial health risk to Resident #1. The facility not only did not permit return, but failed also to provide community services to a vulnerable person who could not, by their assessment and care plan, transfer him/herself from chair to bed, had an indwelling urinary catheter, was dependent on caregivers for hygiene, and had trouble using a telephone. A fax was sent by the facility to the Visiting Nurse Association at 1:30 PM on 4/25/19, with no evidence of any effort to check on Resident #1, and knowing the family was not coming promptly to assist (per interview administrator and DNS, 4/30/19 at 9:00 AM). | 2020-09-01 |