cms_VT: 96
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
96 | THE PINES AT RUTLAND CENTER FOR NURSING AND REHABI | 475018 | 99 ALLEN STREET | RUTLAND | VT | 5701 | 2017-10-10 | 323 | G | 1 | 0 | 7SD111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews and record review the facility failed to provide adequate supervision or assistance devices to prevent accidents for one applicable resident (Resident #2). Findings include: Per record review Resident #2 has multiple [DIAGNOSES REDACTED]. Per review of Resident #2's activities of daily living care plan, s/he was non-ambulatory and required one assist with personal hygiene, dressing, and bathing. Per review of the nurse's notes dated [DATE], the nurse heard a sound, went to Resident #2's room and found the resident lying on his/her back between the beds on the floor. The Licensed Nursing Assistant (LNA) had been performing a bed bath at this time. Resident #2 was assessed and had a large hematoma (blood filled bump) and abrasion on his/her head. Resident #2 was sent to the Emergency Department via ambulance for an evaluation. Per physician progress notes [REDACTED].#2 was on comfort measures, had a fall during a bed bath at the nursing home, and had a consequent head injury. Per review of the facility incident report from [DATE], Resident #2 had expired on the evening of [DATE]. Per interview with a Licensed Nursing Assistant (LNA) on [DATE] at 10:00 AM, s/he stated that on [DATE] at approximately 4:00 PM, s/he walked into Resident #2's room to perform afternoon care. S/he gathered all supplies needed for care and set them on the bedside table. S/he had finished performing care on all of Resident #2's body except for his/her bottom area. S/he washed Resident #2's front and then positioned Resident #2 to cleanse his/her back. The LNA positioned Resident #2 on his/her right side with his/her left leg over the right leg. S/he stated that s/he turned his/her head away from Resident #2 for approximately 3 seconds to get some ointment; and as s/he turned his/her head back; Resident #2 had rolled off the bed and hit the floor. The LNA stated s/he was on the left side of the bed; the bed was at waist level, Resident #2 did not use side rails, and that Resident #2 was positioned in the middle of the bed, closer to the edge of the right side of the bed away from the LN[NAME] Per interview with a Licensed Practical Nurse on [DATE] at 2:05 PM, s/he stated that s/he was passing medications and was just in Resident #2's room and had seen the LNA performing care for Resident #2. S/he stated that s/he had left the room and seconds later s/he had heard a loud thud. S/he went into the room and found Resident #2 lying on the floor on his/her back in a pool of blood. S/he stated that the bed was in a high position and that the resident did not have side rails. | 2020-09-01 |