cms_VT: 55
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
55 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2018-10-24 | 658 | F | 0 | 1 | 73OO11 | Based on record review and staff interview the facility failed to assure that the care plans for residents were developed, revised or reviewed and approved by a Registered Nurse for 22 of 31 residents (Residents# 312, 18, 61, 87, 108, 49, 62, 311, 309, 72, 31, 57, 25, 4, 101, 34, 6, 93, 20, 43, 42, 9) reviewed in the sample, and this has the potential to affect all residents of the facility. Findings include: 1). During the record reviews of care plans it was noted that for a majority of the care plans reviewed in the Electronic Medical Record (EMR), there were either entire care plans initiated or partially initiated by Licensed Practical Nurses (LPN's), or revisions by LPN's throughout the care plans reviewed. These care plans were for Residents# 312, 18, 61, 87, 108, 49, 62, 311, 309, 72, 31, 57, 25, 4, 101, 34, 6, 93, 20, 43, 42, 9. In an interview on the afternoon of 10/23/18, the Director of Nursing (DNS) confirmed that LPN's create and revise care plans. Further, there is no sign off by RN's approving the care plan and no process for RN's to review the care plans when completed or revised by LPN's. In the State Board of Nursing Scope of Practice & Decision Tree for RN, APRN, and LPN the following is stated: LPN role in assessment, planning, and implementation of a strategy of care: -LPNs may not independently assess the health status of an individual or group and may not independently develop or modify the plan of care. LPNs may contribute to the assessment and nursing care planning processes; however, patient assessment and care plan development or revision remain the responsibility of the RN/APRN/licensed physician/licensed dentist. -LPNs may not modify a patient care protocol. If the situation and/or data collected by the LPN are not clearly consistent with a protocol, the LPN must consult with the supervising professional or authorized provider before taking action or making a recommendation to a patient. | 2020-09-01 |