cms_VT: 36
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 36 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2019-05-01 | 656 | J | 1 | 0 | IOQ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility failed to implement the written plan of care for 1 of 4 residents in the sample (Resident #1). Findings include: After admission 6/27/18 with [MEDICAL CONDITION] due to trauma, and a history of [MEDICAL CONDITION], the facility developed a care plan based on the assessed needs and preferences of Resident #1. This included a preference to go outside, weather permitting, and risk of social isolation related to change in customary lifestyle, difficulty accepting placement in the center, loss of status and/or freedom, loss of support network, and coping with decline in overall health and functional decline. Staff were directed in the written plan of care to: evaluate mood state or behavioral symptoms impacting social isolation; encourage to make decisions independently and provide positive feedback; encourage expression of thoughts and feelings associated with the change or loss of customary lifestyle/routines; encourage to participate in activity preferences; family and staff to assist outdoors, weather permitting. On 4/18/19, a care plan was also developed for risk of elopement related to history of leaving grounds without signing out. This directed staff to notify the physician, observe location when out of bed, remind to sign out/in when leaving. Additionally the care plan included risk for [MEDICAL CONDITION] activity related to tremors. Monitor for signs/symptoms of impending [MEDICAL CONDITION]. Resident #1 stated during interview on 4/29/19 at 3:30 PM that s/he expressed to facility staff that s/he had not been out of the building all year, that rehab means getting out and mingling with people.Contrary to the care plan which states that staff or family will support the resident to go outside, Resident #1 was allowed to go outside and off the premises a few times alone. On 4/19/19 when Resident #1 left the premises, the facility called police. During the care plan meeting of 4/24/19, Resident #1 asserted the desire to go downtown that afternoon. This was confirmed by a staff witness during interview at 2:15 PM on 4/29/19. The facility did not implement care strategies to safely allow such community activity.The facility instead initiated an Against Medical Advice (AMA) discharge on 4/24/19. Per record review, staff and resident interviews, the resident left the facility and returned on 4/24/19 at least twice after having been considered discharged against medical advice (AMA) by the facility (signature on 4/24/19, 1:00 PM, per AMA document). First the resident was documented as leaving the building to go to a friend's to live. Later, Resident #1 was observed in the building and on the 4th floor at 3:30-4 PM, per interviews with the nurse unit manager (4/29/19 at 12:05 PM) and by 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 in need of housing and was turned away) and returned at approximately 5:00 PM. 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 family and others due to hand tremors preventing the resident from dialing the phone independently. 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 Resident #1 said they would not let him/her back in the building and s/he had no place to go. The resident stated I made a mistake. The OT 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 that's too bad; I'll get him/her a hotel. When interviewed at the hospital on [DATE] at 3:30 PM, the resident said the DNS told me you've got to get out of here; we'll call the cops. The facility had called 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, 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 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 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, 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). Refer to F561. | 2020-09-01 |