cms_VT: 50
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
50 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2017-08-14 | 514 | C | 1 | 0 | DTTL11 | > Based on observation, staff interview and record review the facility failed to ensure that 1 of 5 sampled residents' medical records met acceptable professional standards and practices. For Resident #1 the findings include the following: Per medical record review, Resident #1 had a straight Catheterization on 5/15/17 at approximately 1:47 AM by the Licensed Practical Nurse (LPN). After two unsuccessful attempts a final attempt was conducted by the resident. The LPN confirms that 300-400 cc's of urine was obtained. Per review of the Treatment Administration Record, the LPN initialed the treatment as completed at that time. Per review of the progress notes, there is no documentation that evidences that the Catheterization took 3 attempts before Resident #1's bladder was relieved. Per interview with the LPN on 8/14/17 at approximately 11:45 AM, confirmation was made that h/she does not recall writing a progress note, nor can the LPN offer any explanation as to why the note was not written The Director of Nurses confirmed at the time of the telephone interview that there is no evidence in the Electronic Medical Record that a progress note was written. Per review of the facility policy titled Intermittent Catheter Insertion documentation identifies staff to document the reason for use of intermittent catheter; date and time; color, odor, amount, and description of urine; and patient's response. | 2020-09-01 |