cms_VT: 40
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
40 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2019-05-01 | 745 | 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 provide professional, medically related social services to ensure 1 of 4 residents sampled (Resident #1) attained their highest practicable physical, 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, 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/or professional, medically-related social services 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 closer to home. Per interview with the Nurse Practitioner (NP), 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. During the above interviews, the Administrator, DNS, and NP referred to Resident #1 as non-compliant with various aspects of care and services. 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 his/her 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. Despite leaving and returning to the facility that afternoon at least twice, indicating s/he had made a mistake, 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 |