cms_VT: 86
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
86 | THE PINES AT RUTLAND CENTER FOR NURSING AND REHABI | 475018 | 99 ALLEN STREET | RUTLAND | VT | 5701 | 2018-06-28 | 580 | D | 0 | 1 | WX2411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family and staff interviews and record review, the facility failed to notify the resident's representative immediately at the time of a significant change in condition; and of a room change, for 2 residents in the applicable sample (Resident #92 and Resident #372). Findings include: 1. Per record review for Resident #92, progress notes identify the following: -6/12/18 at approximately 23:15 (11:15 PM), the resident complained of not being able to swallow and the resident's tongue was slightly swollen. Supervisor notified; -6/13/18 at approximately 02:20 (2:20 AM), the resident still complaining of not being able to swallow well and tongue more swollen. Hospice Nurse notified and will come into the facility to assess the resident; -6/13/18 at approximately 03:00 AM, Hospice Nurse assessed the resident and concluded the resident was having a reaction to the antibiotic, that began on 6/12/18. Nurse Practitioner (NP), contacted and orders received for treatment; -6/13/18 at approximately 03:45 AM, medications administered; -6/13/18 at approximately 04:30 AM, Hospice Nurse left the facility, but provided nursing staff with instructions if condition changes; -6/13/18 at approximately 07:00 AM, resident still complaining of trouble swallowing and tongue remains swollen; -6/13/18 at approximately 07:34 AM medication administered for [MEDICATION NAME] ( a severe, potentially life-threatening allergic reaction); -6/13/18 at approximately 08:00 AM NP on site, assessed resident and injectable medications administered; -6/13/18 at approximately 11:34 AM progress notes identify family communication. Per family interview on 6/25/18 at 12:00 PM, on 6/27/18, and on 6/28/18 at approximately 12:30 PM, the notification of Resident # 92's allergic reaction/[MEDICATION NAME] did not occur until 6/13/18 at approximately 7:20 AM. Per interview on 6/27/18 with an Administrator from Hospice, s/he confirmed that the hospice nurse was on site on 6/13/18; and did not notify the family of the resident's condition at the time of his/her assessment/visit. 2. Per record review Resident #372 was transferred from room [ROOM NUMBER] to room [ROOM NUMBER] on 6/26/18. There was no evidence in the medical record that the resident and/or resident's representative was notified of the room change prior to the room change taking place. Per interview on 6/27/18 at 8:24 AM with the social worker, s/he confirmed that the resident and/or resident's representative was not notified of the room change. | 2020-09-01 |