cms_VT: 39
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
39 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2019-05-01 | 742 | J | 1 | 0 | IOQ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interviews, the facility failed to ensure 1 of 4 residents sampled (Resident #1) received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being, related to trauma, new [MEDICAL CONDITION] with loss of independence, adjustment problems, and a history of [MEDICAL CONDITION]. Findings include: Per record review, the facility failed to ensure that the resident received appropriate treatment and services to correct his/her alcohol dependence, risk of isolation, and feelings of loss of freedom and independence, and coping with an overall decline in health and function, as stated in the written plan of care and diagnoses. The resident, age 64, was rendered paraplegic by trauma and was admitted to the facility 6/27/18. Record review shows no evidence that the resident was referred for professional mental health assessment and treatment to address these issues of trauma, loss, addiction, and adjustment from admission through discharge 4/24/19. During interview on 4/29/19 at 12:30 PM, the social worker described having routine care conferences and doing some research to find placement closer to family. On 4/30/19 at 9:00 AM the Director of Nursing and administrator related difficulty finding an alternate placement. Per interview with the nurse practitioner, 4/30/19 at 9:35 AM, s/he confirmed that s/he was unaware of any psychological referral. Record review showed that at least 3 facilities had refused admission. The nearest family lives 2 hours away. From admission through 1/22/19, Resident #1 was allowed 1 beer per day, and had a medical order for this. Due to an incident on 1/21/19 where staff observed Resident #1 allegedly having more than 1 beer with 2 other people, the medical order for 1 beer per day was discontinued. There was no evidence to suggest that Resident #1 received referral or treatment for [REDACTED]. Resident #1 did show a change in behaviors from that time until 4/24/19. This included an elopement on 4/19/19 to assert the right to leave the premises. When Resident #1 again left the premises on 4/24/19, an AMA (against medical advice) process was initiated by the facility. Facility staff, not the resident, initiated the discussion about discharge AMA when the resident was adamant about wanting to socialize independently outside the facility that day. Despite leaving and returning to the facility that afternoon at least twice, the facility moved forward with a less than orderly discharge to a hotel, alone and without care. This culminated in emergency services and transport to hospital for treatment of [REDACTED]. | 2020-09-01 |