cms_VT: 41
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
41 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2019-05-01 | 842 | D | 1 | 0 | IOQ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon record review and interview, the facility failed to assure that 1 of 2 resident health records was accurately documented by the social work staff. (Resident #2). Finding include: 1. Per record review, Resident #2's care plan completed by the Social Worker (SW) dated 4/8/19, states Resident #2 has impaired/decline in cognitive function or impaired thought processes related to a condition other than [MEDICAL CONDITION]. The interventions include monitor conditions that may contribute to cognitive loss/dementia, including metabolic causes, respiratory problems, [MEDICAL CONDITION], delusions, hallucinations, psychiatric disorder, poor nutrition, hearing or vision impairment, new/acute heath problem, head injury, pain fever, dehydration or alcohol withdrawal. Evaluate needs for psych/behavioral health consult. Per record review of the Brief Interview for Mental Status (BIMS), which was completed upon admission by the social worker, states Resident # 2 has a score of 15. BIMS is used to obtain a snapshot of how well a person is functioning at the moment. A score of 13-15 is cognitively intact. SW stated that Resident #2 was mentally alert and cognitively intact. Per staff interview, the SW confirmed on 4/30/19 at 8:15 AM that the care plan for Resident #2 was inaccurate as written on 4/8/19 and the resident was mentally alert and cognitively intact. The SW did not correct the inaccurate documentation in the care plan prior to Resident #2's discharge on 4/25/19. SW stated the computer generated care plan auto populates and staff completing the care plan need to make adjustments as needed. Stated she/he should have revised the care plan. | 2020-09-01 |