cms_VT: 65
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 65 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2017-12-14 | 656 | D | 0 | 1 | 0QUX11 | Based on observation, record review and confirmed by staff interview the facility failed to implement the person-centered care plan for 2 of 23 sampled residents. The care plan has not been developed to maintain Resident #45's safety and prevent falls and Resident #27, for toileting needs. The findings include the following: 1). Per review of Resident #45's medical record, it identifies that the resident is at end stage Kidney Disease and has been receiving Hospice services. The resident is at risk for falls. In the month of (MONTH) (YEAR), falls have occurred on 12/1/17 and 12/11/17. The Interdisciplinary Care Plan identifies that Resident #45 is to be in a supervised area when out of bed. Per observation on 12/13/17 at 1:05 PM, Resident #45 was in the TV lounge, in a recliner and sitting upright with both legs elevated. No staff presence identified. At 1:07 PM an Licensed Nurse Aide (LNA) enters the lounge and removes lunch trays. At 1:15 PM an LNA walks through the area. At 1:30 PM, the Registered Nurse (RN) staff educator enters the lounge and sits with Resident #45. Fluids that have been sitting on the table in front of the resident, are offered. The RN provides the resident with a blanket and leaves the area. At 1:33 PM, the resident is sound asleep in the TV lounge unattended. At 1:40 PM the RN directs staff to assist the resident to bed. Per interview with the RN at 1:40 PM, confirmation was made. that the Resident #45, has been left unattended in the TV Lounge. S/He also confirms that care plan does identify that the resident is to be attended when out of bed. 2). Per observations, record review and an anonymous voiced concern, Resident # 27's care needs for toileting, per the care plans, were not implemented. Review of the care plan and Kardex denotes the following: Adhere to toileting plan every 2 hours upon arising .Provide (Resident #27) with extensive, assist of 1 for toileting .Use grab bar in bathroom for transfer When it is time for toileting (Resident) may respond better to telling (resident) that it is time to go to the bathroom rather than do you have to go to the bathroom. Per observation on 12/12/17 at 4:30 P.M., Resident #27 was being wheeled down to small dining area by the Activity staff. The activity person stated the resident was in a music activity (downstairs) plus another activity (on this floor) since before 2 P.M. Per interview at 5: 07 P.M., LNA #1 & LNA #2 acknowledged that since they came on the floor/shift at 2:45 P.M. they have not checked nor toileted the resident. They were aware of the 2 hour toileting plan but thought the resident was changed by LNA #3, who was working during the day and this evening. During interview, a short time late, LNA #3 stated that for this resident, per family wishes, other LNAs are assigned for perineal-care and like services and did not provide toileting LNA #3 was not aware of who provided the toileting care between 2:00 P.M. and 5:00 P.M. Per interview on 12/13/17 at 8:20 [NAME]M., the Activity Director (AD) acknowledged the resident had been in activities the day before, from just before 2 P.M.(music downstairs), and went to another activity from 3:00 P.M. to 4:30 P.M. (upstairs). Per continued observations on 12/13/17 the following occurred: 9:15 [NAME]M. resident observed on the Unit, wheeled to up a table in the TV area. 9:22 Resident looking around trying to signal nurse surveyor and asked go to the bathroom. There was no call bell or other method to alert staff if needed. The resident was unable to demonstrate the ability to self-propel. Nurse Surveyor was unable to find available LNAs at this time. All busy providing morning care in other resident's room. 9:35 [NAME]M.- LNA #1 acknowledged ''will be right there, almost finished here''. (In another resident's room) 9:54 [NAME]M. Activity Staff arrived and asked resident if (s/he) wanted to go to activity, which the resident replied yes and started to wheel her towards the nursing station. The nurse surveyor at this time stated that the resident has been waiting greater than half an hour for assistance to go to the bathroom. The Activity person then brought the resident back to the room and found another LNA #2. 10:00 [NAME]M. LNA #1 stated that (s/he) as well as LNA #2 were late today (weather) and didn't get in until 8:00 [NAME]M Neither LNA stated that they toileted resident #2 since they started work. 10:17 [NAME]M. The DNS was aware that staff did go around and do the toileting around 730ish but acknowledged that Resident #27 had no way to ask for assistance and staff were late in providing care according to the care plan, (greater than 2 hours). | 2020-09-01 |