cms_VT: 7
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7 | VERNON GREEN NURSING HOME | 475008 | 61 GREENWAY DRIVE | VERNON | VT | 5354 | 2019-09-18 | 689 | D | 0 | 1 | XBZR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, direct observation and staff/resident interviews, the facility failed to ensure that the environment was free of accident hazards for 1 applicable resident, (Resident #24). The findings are as follows: As the evidence demonstrates below, after Resident #24 sustained a burn from spilling hot coffee, the facility failed to adequately address all areas of potential hazards for Resident #24 to prevent further accidents. Per medical record review, Resident #24 [MEDICAL CONDITION] 08/29/19 to his/her right leg extending from the top of the resident's thigh to the back of the right knee. The resident reported spilling coffee while independently self-propelling his/her wheelchair back to his/her room. The burn was assessed by the nursing staff; the physician was notified and ordered daily of cleansing and dressing the wound until healed. Per review of the physician's progress note dated 09/03/19, reads, a few days ago resident was drinking coffee and it spilled on self, resulting in erosion of the skin on the thigh and vesicle (blister) formation. The fluid filled vesicle's opened, drained and are beginning to heal. Burn is superficial and does not extend to the dermis. Per interview on 09/17/19 at approximately 1 PM with the resident and a family member, the resident denies any pain or discomfort at present and voiced that s/he is to blame for spilling the coffee on him/herself. Per review of the Minimum Data Set assessment (MDS), a federally mandated assessment dated [DATE], the resident is identified as having cognitive deficits and often refuses to allow staff to assess him/her. S/he requires supervision with locomotion on and off the unit; and needs supervision and set up for eating. On 08/29/19, as a result of this incident, the care plan was updated and indicated that nursing is to ensure lids and straws are used at all times while drinking coffee. Education was provided to the LNA staff related to the management of transporting hot beverages for Resident #24 on 08/29/19 and on 08/30/19 regarding transporting hot liquids from one location to another by residents. Nurses notes identify on 08/29/19 at 4:30 PM (2 hours after notification about the initial burn), the resident carried his/her hot soup and coffee after supper on his/her lap back to his/her room. Staff offered to transport, but the resident refused. There is no evidence in the nurses notes that staff provided education of risks at the time of refusal of assistance. There are also instances documented in the nurses notes identifying the resident requesting soup or coffee to be heated during the overnight shift and early mornings. There is no evidence that temperatures of the heated coffee or soup were monitored or checked prior to delivery to Resident #24 during the overnight shift. The surveyors with the Administrator, Food Service Director and the Director of Nurses (DNS), checked the temperatures with a calibrated digital thermometer, of hot water and hot coffee during the evening meal on 09/16/19, on 09/17/19 all three meals were checked and on 09/18/19 breakfast and lunch liquids were checked. The results identified black coffee and hot water temperatures varied from as high as 164 degrees to as low as 142 degrees Fahrenheit. Through the investigation, it was discovered that temperatures of hot liquids are not routinely checked by facility staff prior to serving residents. On 09/17/19 at 7:37 AM, the surveyor observed twelve residents eating breakfast in the activity room across from the nurses' station on A-Wing. LNA staff were observed to be in and out of the room and the Licensed Practical Nurse (LPN) was administrating medications. At 8:00 AM, unsupervised, Resident #24 placed a full cup of water and hot coffee upon his/her lap and propelled him/her-self approximately 20-25 feet to his/her room. The surveyor witnessed the hot coffee in the resident's lap had spilled out of the lid onto his/her thigh. At 8:05 AM, the LPN confirmed that the resident's pants at the knee area was wet and removed the cup of coffee from the resident's room. The surveyor in the presence of the LPN tested the coffee with a calibrated digital thermometer and it registered 122 degrees Fahrenheit. As a result of the second incident that was brought to the facility's attention by the surveyor, Resident #24 was provided with hard plastic spill proof mugs, that enables him/her to independently transport coffee at any time without the risk of spillage. | 2020-09-01 |