cms_VT: 94
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
94 | THE PINES AT RUTLAND CENTER FOR NURSING AND REHABI | 475018 | 99 ALLEN STREET | RUTLAND | VT | 5701 | 2017-10-10 | 152 | D | 1 | 0 | 7SD111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interviews and record review the facility failed to adequately consider a choice made by the resident's representative on the formal side rail assessment for the use side rails on a bed for safety for one applicable resident (Resident #1). Findings include: Per record review, Record #1 has a [DIAGNOSES REDACTED]. S/he relies on his/her representative to make decisions regarding his/her care. S/he has had two documented falls at the facility on 4/30/17 and 5/7/17; and per a facility incident report dated 9/23/17, on 9/15/17, during the overnight shift, Resident #1 was found with his/her body askew and head resting on bedside mat. Per observation during the survey on 10/9/17 & 10/10/17, the resident had a bariatric bed with an air mattress and the bed did not have side rails. Per telephone interview on 10/5/17 at 9:48 AM with the resident's representative, s/he stated that s/he wanted Resident #1 to have padded side rails on his/her bed for safety. S/he stated that Resident #1 has already had two or three falls in the facility; and that when Resident #1 was in another facility, s/he had a bed with padded side rails and had no falls. During interviews on 10/9/17 and 10/10/17 with the Administrator and Director of Nursing, they confirmed that the resident's representative did want side rails used for Resident #1's safety. They stated that Resident #1 was not a candidate for side rails as the side rails posed more of a risk for Resident #1's safety. They stated that the facility has implemented multiple interventions to ensure that the Resident #1 is safe without the use of side rails. On 5/1/17, the facility evaluated Resident #1 for the use of side rails. The side rail evaluation inaccurately identified that the resident (in this case the legal representative) did not express a desire for siderails, stating, 1. Has the resident expressed a desire to have Side rails while in bed for their own safety and comfort? 'N' Interdisciplinary Team Recommendation: Side rails will not be used at this time. Per the previously stated interview, the resident's representative had repeatedly expressed a desire for the resident to have side rails while in bed for his/her own safety. There was also no evidence in the medical record that Resident #1 had been re-evaluated for the use of side rails since 5/1/17, which was prior to the second and third incidents. Per interview with the Unit Manager on 10/10/17 at approximately 12:59 PM, s/he confirmed that the resident had not been re-evaluated for the use of side rails since 5/1/17 and that the resident's representative had desired that side rails be used for Resident #1's safety. | 2020-09-01 |