cms_VT
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2,517 rows sorted by deficiency_tag
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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag ▼ | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2149 | 2149 | THOMPSON HOUSE NURSING HOME | 475050 | 80 MAPLE STREET | BRATTLEBORO | VT | 5302 | 2012-01-25 | 151 | D | 1 | 0 | 0U7L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that one resident reviewed in the sample (Resident #1) was free to exercise his/her rights as a resident of the facility and as a citizen of the United States. The findings include: Based on interview and record review, Resident #1 was isolated for an extended period of time and was limited in the amount of time that the resident could interact with the facility population. 1. Per medical record review on 1/23/12, Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Per review of Resident #1's medical record, Resident #1 is alert and oriented and per review of the Psychiatric evaluation dated 11/08/11, indicated that Resident #1 "is violent to other residents at times." The evaluation also stated that for Resident #1 there is a "question of mental [MEDICAL CONDITION], though (he/she) is quite highly functioning." Review of the admission paperwork, indicates that Resident #1 does not have a legal guardian and per interview with the facility Administrator on 1/25/12, Resident #1 is able to make his/her own decisions. Per the medical record, Resident #1 had physical altercations with other residents on 11/19/11, 12/30/11 and 1/13/12. Per review of the nurse's notes, Resident #1 scratched the face of another resident and the facility's immediate intervention was to confine Resident #1 to his/her room and only allow Resident #1 out of the room for supervised phone calls with staff and supervised activities during the timeframe of 11/19 until 11/28/11 (total of 9 days). Per nurse's notes on 12/30/11, Resident #1 "slapped" the hand of a resident that utilized Resident #1's walker to stabilize his/her self to stand. The facility's immediate intervention was to confine Resident #1 to his/her room for a time period of 12/30/11 to 1/1/11. Resident #1 was allowed out of room only with supervision to utilize the phone. Per review of the nurse's notes dated 1/13/12, Resident #1 "kicked" another resident who was in hi… | 2015-05-01 |
| 94 | 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' Interd… | 2020-09-01 |
| 128 | 128 | ST JOHNSBURY HEALTH & REHAB | 475019 | 1248 HOSPITAL DRIVE | SAINT JOHNSBURY | VT | 5819 | 2017-06-07 | 154 | D | 1 | 0 | UYHZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interviews, the facility failed to ensure the resident (and if not competent to make their own decisions, their legal representative) has the right to be informed in advance of changes to the plan of care for 1 applicable resident regarding medication changes. (Resident #1) The specifics are detailed below: Per medical record review, Resident #1's care plan includes cues for staff to include the family and health care agent of medication changes, of any changes in care provided and any treatment changes. Family are present at care planning meetings on 2/03/2017, 2/15/2017 and 3/20/2017; however, there is no evidence to indicate that medication changes or additions were discussed with or approved by the family during those times. [MEDICATION NAME], a medication used in the treatment of [REDACTED].# 1. The family was not part of the initial conversation about starting these medications. The Unit Manager confirms, during interview on 6/7/17, that the family was not involved in all of the care planning decisions for this resident. | 2020-09-01 |
| 2085 | 2085 | CRESCENT MANOR CARE CTRS | 475033 | 312 CRESCENT BLVD | BENNINGTON | VT | 5201 | 2012-03-23 | 154 | G | 1 | 0 | JN5K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and Power of Attorney (POA) interviews, the facility failed to fully inform 1 resident or his/her legal representative about changes in the treatment plan by not informing them that an as needed (PRN) medication would be withheld for escalating behaviors, that the resident would be sent to the hospital and would not be accepted back at the facility. The findings are as follows: Per medical record review on 03/08/2012 at 1:10 PM, the facility administration placed a notice in the record and on the nurses' unit on or about 01/05/2012 or 01/06/2012 instructing staff to not give Resident # 1 the ordered PRN medication, [MEDICATION NAME], for escalating behaviors, which is contrary to MD orders and directions in the care plan dated 12/06/2011. The notice further instructed the staff to call the police department, the ambulance, facility personnel, the physician and the POA, to send the resident to the hospital and not accept him/her back into the facility if hospital admission did not occur. The notice is not signed or dated and there is no evidence to support that the physician was included in formulating this change in the treatment plan. This is confirmed by facility staff during interview on 03/09/2012 between 10 and 11 AM. Per telephone interview with Resident #1's Power of Attorney (POA) on 03/12/2012 at 10:30 AM, s/he confirms that s/he was not notified of this plan until after it was implemented. S/he attended a care plan meeting on 12/06/2011 and recalls from notes made at the time that there was no mention of Resident #1 not being appropriately placed at this facility, nor that it was the facility intent to discharge Resident #1 from the facility. Further, there were no indications that any changes were made in the care plan. This is supported in the medical record notes from the care plan meeting in [DATE]. | 2015-07-01 |
| 1027 | 1027 | GREENSBORO NURSING HOME | 475043 | 47 MAGGIE'S POND ROAD | GREENSBORO | VT | 5841 | 2017-05-31 | 155 | D | 1 | 0 | Deficiency Text Not Available | 2018-08-01 | |
| 1228 | 1228 | PINES REHAB & HEALTH CTR | 475044 | 601 RED VILLAGE ROAD | LYNDONVILLE | VT | 5851 | 2015-02-25 | 155 | G | 0 | 1 | OM9D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assure that 1 of 20 residents had the right to refuse medication (Resident #15). Findings include: Per interview and record review, Resident #15 was physically restrained by staff in order to administer an intramuscular (IM) injection of an antipsychotic medication against his/her will. Resident #15 had [DIAGNOSES REDACTED]. The physician wrote orders for antipsychotic medication that was to be used to alleviate aggressive behaviors as needed. There is a signed order from 4/29/13 for an oral medication [MEDICATION NAME] 2 milligrams (mg.) one tab QID (four times daily)PRN (as needed) for aggression. The same telephone order has also [MEDICATION NAME] 2 mg IM (Intramuscular injection) BID (twice daily) if unable to take PO. Per review of the nurse's notes from 1/20/15, at approximately 2:00 PM the resident was acting aggressively toward the nurse on duty by trying to take the Medication Administration Record [REDACTED]. The note stated that the resident was escorted to their room by an LNA (Licensed Nursing Assistant) and the LPN (Licensed Practical Nurse), and offered an oral dose of [MEDICATION NAME] 2 mg., which Resident #15 refused to take. The note continued to state that the nurse gave [MEDICATION NAME] 0.4 ml (2 mg.) IM to R butt cheek with LNAs assisting me to restrain (him/her). Per interview on 2/24/15 at 2:45 PM, the LPN who administered the injection stated that Resident #15 was very riled on the afternoon of 1/20/15, and was getting very aggressive, especially targeting the nurse. There was concern for the safety of others, so Resident #15 was escorted to their room by staff and offered a PRN [MEDICATION NAME] by mouth. After the resident refused, the nurse chose to give the medication by injection. The account given by the nurse was that one LNA held the residents arms and another held the resident's legs, and the nurse gave the injection into the buttocks of the reside… | 2017-12-01 |
| 1235 | 1235 | WOODRIDGE NURSING HOME | 475045 | P.O. BOX 550 | BARRE | VT | 5641 | 2014-12-15 | 155 | D | 1 | 0 | 6VHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record, policy and facility investigation review, the facility failed to ensure that the right to refuse treatment was respected for 1 of 3 residents in the survey sample (Resident #1). Findings include: Per record review on 12/15/14, Resident #1 had [DIAGNOSES REDACTED]. S/he had care plans in place for cognitive deficits related to the stroke and behavior problems which included paranoia. His/her behavioral care plan stated that if Resident #1 is being verbally abusive, leave the room and reapproach as needed and if Resident #1 asks staff to leave (his/her) room, do so without question. Send other staff members in to assist (him/her). Under Resident #1's care plan for alteration in cognition, the care plan states, Resident #1 may refuse treatments/medications at times .respect refusals and update MD as needed. Per 12/15/14 review of the nursing progress notes, on 10/15/14 an LNA (Licensed Nursing Assistant) came from Resident #1's room, very upset and reported to a staff nurse that s/he . can't deal with (Resident #1) anymore, (s/he's) being mean and saying terrible things. I don't even want to go in there anymore. The note documents that the nurse entered Resident #1's room with the same LNA and Resident #1 told the staff nurse I don't want (the LNA) in here, I don't like (him/her). The nurse told the resident that s/he would be in there while the LNA provided care. The nurse, with the LNA still present in the room, asked Resident #1 what the LNA did and the resident stated, s/he's .an idiot and I don't want (him/her). The nurse then documented telling Resident #1, that s/he needed a better reason than that and (Resident #1) .thought for a few seconds and then stated (S/he's) abusive. The nurse asked the resident to be more specific. Resident #1 then alleged that the LNA had hit him/her in the face with a washcloth, hit him/her in the (left) arm and indicated that s/he had hit his penis. The note then d… | 2017-12-01 |
| 1588 | 1588 | DERBY GREEN NURSING HOME | 475048 | PO BOX 24 | DERBY | VT | 5829 | 2014-01-16 | 155 | D | 1 | 0 | 322311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure the right to refuse treatment for 1 of 3 residents in the survey sample (Resident #2). Findings include: Per review of the clinical record on 1/6/14, Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the annual MDS dated [DATE], s/he can sometimes make him/herself understood and usually understands others. On a brief test of cognitive function, s/he scored in the intact range; s/he requires limited assistance for transfers and uses a wheelchair. Per 1/6/14 review of physician orders, Resident #2 was prescribed [MEDICATION NAME] (Aripiprazole) 5 mg at 8 AM; if does not take PO, gets 9.75 mg IM (PO= by mouth; IM= by intramuscular injection). Per review of the nursing progress notes dated 12/17/13 at 10:52, [MEDICATION NAME] 9.75 mg/1.3 ML Solution was given for refusal of PO medication per MD order. Reason: Refused Aripiprazole 5 mg tablet. Per 1/6/14 interview at 3:45 PM with the nurse administering the [MEDICATION NAME] injection on 12/17/13, s/he reported at the time of the injection, the facility had 6 staff members present in the room; it was the first time we had ever given the shot, so we wanted to be sure no one would get hurt. Resident #2 told me, No but if (s/he) really didn't want the shot, (s/he) could have prevented me from giving it. The order is written to give [MEDICATION NAME] IM if refuses the PO form. Per review of nursing progress notes dated 12/21/13, the nurse documented, resident refused Aripiprazole 5 mg tablet .[MEDICATION NAME] 9.75 mg/1.3 ML Solution given for refusal of po. Per review of nursing progress notes dated 12/28/13, . When told at 10:00 that (s/he) needed to take (his/her) pills or it was going to be too late stated 'no' when asked if (s/he) would take them. Explained that because of (his/her) behavior history my orders were that if (s/he) didn't take (his/her) [MEDICATION NAME] by mouth that (… | 2017-01-01 |
| 1789 | 1789 | ST JOHNSBURY HEALTH & REHAB | 475019 | 1248 HOSPITAL DRIVE | SAINT JOHNSBURY | VT | 5819 | 2013-03-04 | 155 | D | 1 | 0 | Y9J811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to honor the right to refuse treatment for 1 of 3 residents in the applicable sample (Resident #1) when the nurse provided cardiopulmonary resuscitation (CPR) despite knowledge of a Do Not Resuscitate (DNR) designation in the medical record. Findings include: 1. During record review on [DATE], the medical record of Resident #1 was found to contain a Living Will document which was signed by Resident #1 and two witnesses on [DATE]. The Living Will specified the wishes of Resident #1 as not to receive artificial respiration or cardiopulmonary resuscitation. The physician's orders [REDACTED]. The Alert Conditions page in the medical record was flagged DNR/DNI. The Kardex card for Resident #1, a reference for staff in providing care according to the written plan of care, contained a DNR/DNI notation. Resident #1 was designated on the face sheet of the medical record as his/her own guarantor. There was no evidence in the medical record of a legally designated guardian or durable power of attorney for healthcare for Resident #1. The facility's written policy statement for Do Not Resuscitate Order states, Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. The nurse notes dated [DATE] specified that Resident #1 was found unresponsive at 7:25 AM. The nurse was unable to auscultate (hear with a stethoscope) a heartbeat or blood pressure. The spouse was informed of the DNR designation, yet requested everything done. The written nurse notes further state that 911 was called, and that the nurse started cardiopulmonary resuscitation at 7:30 AM. During an interview on [DATE] at 12:17 PM, the nurse stated that s/he had sent another nurse to check the medical record and s/he was aware of the DNR status for Resident #1 prior to performing CPR on [DATE]. | 2016-03-01 |
| 2344 | 2344 | PINES REHAB & HEALTH CTR | 475044 | 601 RED VILLAGE ROAD | LYNDONVILLE | VT | 5851 | 2011-03-23 | 155 | G | 1 | 1 | UUVM11 | Based on record review and interviews, the facility failed to assure staff honored 1 applicable resident's right to refuse treatment (Resident #66). Findings include: Per review of written statements, interview, and record review, LPN #1 failed to honor Resident #66's right to refuse disrobing and bathing on 3/11/11. Per review of written incident reports dated 3/11/11, two Licensed Nurse Assistants (LNA) summoned the Licensed Practical Nurse (LPN #1) on duty when Resident #66 resisted their effort to take him/her for a scheduled bath. The LNA's documented their witness of LPN #1 then wheeling Resident #66 backward toward the tub room while s/he screamed. Furthermore, per written incident report dated 3/11/11, and confirmed during an interview on 3/22/11 at 2:15 PM, LPN #2 (who came to the tub room from a nearby unit to investigate the screaming) confirmed that LPN #1 continued his/her attempts to pull down the pants of Resident #66 while the resident was "screaming for her to stop", the resident also begged for help, saying s/he was bring attacked, and stated "look what they're doing to me." LPN #2 further wrote in his/her statement and confirmed during the interview on 3/22/11 at 2:15 PM that Resident #66 calmed down enough to have a bath when LPN #2 used reassuring approaches as outlined in the plan of care for alteration in psychosocial/mood/behavior. Per record review on 3/23/11, the written plan of care for Resident #66 specified staff approaches for alteration in psychosocial/mood/behavior including: Allow "R" (Resident) to express frustrations, anxiety and allow "R" space; validate feelings with TLC (Tender Loving Care); and Reassure. In an interview on 3/23/11 at 12:56 PM, the Director of Nursing (DON) confirmed that the actions of the nurse on 3/11/11 were not consistent with the written approaches on the plan of care for alteration in psychosocial/mood/behavior, as s/he wheeled the resident backwards and attempted disrobing while the resident screamed and resisted. See also F241, F282. | 2014-07-01 |
| 459 | 459 | GREENSBORO NURSING HOME | 475043 | 47 MAGGIE'S POND ROAD | GREENSBORO | VT | 5841 | 2017-01-25 | 156 | B | 0 | 1 | NOE211 | The facility failed to ensure that residents were informed of their rights and of all rules and regulations governing resident conduct and responsibilities, both orally and in writing, for 2 of 3 residents (Resident #40 & #2). Findings include: During interviews on the afternoon of 1/24/17, Social Service staff reported that residents and/or their representatives receive an admission packet which includes resident rights. The information is explained orally and then the resident or their representative signs the admission agreement acknowledging receipt of the written rights information. After review of Resident #40 and Resident #2's facility folder, the Social Service staff confirmed that there was no evidence that a written admission agreement detailing resident rights in the facility was given to or signed by either Resident #40 or Resident #2 or their representatives. | 2020-09-01 |
| 736 | 736 | ELDERWOOD AT BURLINGTON | 475030 | 98 STARR FARM RD | BURLINGTON | VT | 5408 | 2016-10-11 | 156 | B | 1 | 0 | NX6U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews the facility failed to assure that residents were informed both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility and of of services available in the facility and charges for those services. The finding was for 4 of 12 resident records reviewed (Residents #1, #4, #6, & #8). Findings include: Per record review, admission paper work was not consistently presented to the resident or the responsible party prior to or at the time of admission. According to record review, R#1 was admitted on [DATE] and the Responsible Party signed the Admission Agreement, containing the required information, on 7/28/16. R #4 was admitted on [DATE] and the Admission Agreement was signed on 7/26/16. R #6 was admitted on [DATE] and the Admission Agreement was signed on 9/21/16. R #8 was admitted on [DATE] and the Admission Agreement was signed on 9/22/16. In interview on 10/11/16 at 3:35 PM the Director of Nursing Services (DNS) acknowledged that the Admission Agreements for the above residents were not signed prior to or at the time of admission. | 2019-10-01 |
| 1046 | 1046 | THOMPSON HOUSE NURSING HOME | 475050 | 80 MAPLE STREET | BRATTLEBORO | VT | 5301 | 2015-05-13 | 156 | C | 0 | 1 | FZVD11 | Based on observation and confirmed by administrative staff, the facility failed to post the correct telephone number for the State Licensure Office, the office whereby a resident may file a complaint concerning abuse, neglect and misappropriation of resident property. The findings include the following: Per facility tour on 5/12/15 at approximately 3 PM, posters prominently displayed on both nursing home units, evidenced the incorrect telephone number of the office of Licensing and Protection. Confirmation was made by both the Social Service Designee on 5/13/15 at 2:45 PM and the Licensed Nursing Home Administrator at approximately 3:30 PM that the number was in fact incorrect. | 2018-07-01 |
| 1137 | 1137 | BERLIN HEALTH & REHAB CTR | 475020 | 98 HOSPITALITY DRIVE | BARRE | VT | 5641 | 2015-03-18 | 156 | B | 1 | 0 | HZ2I11 | Based on financial record review and staff confirmation, the facility failed to timely inform 2 of 6 applicable residents, (Resident #55 and #67) in writing, that their Medicare benefits were not accessible. The findings include the following: 1. Per financial record review and interview with the Office Manger (OM) on 3/16/15 at approximately 8:15 AM, a Notice of Medicare Non-Coverage was provided to Resident #55 identifying that the Medicare benefit would end on 2/17/15. The letter provided to Resident #55 was not signed by the resident, their representative or any facility staff. The OM confirms there is no signature on the notice of Medicare non coverage nor is there documentation supporting that the notice was provided to Resident #55. Therefore, it is not possible to confirm that the notice was actually provided to the resident. 2. Per financial record review and interview with the Office Manger (OM) on 3/16/15 at approximately 8:30 AM, a Notice of Medicare Non-Coverage was provided to Resident #67 identifying that the Medicare benefit would end on 1/1/15. The letter provided to Resident #67 is not signed by the resident, their representative or any facility staff. The OM confirms there is no signature on the notice of Medicare non coverage nor is there documentation supporting that the notice was provided to Resident #67. Therefore, it is not possible to confirm that the notice was actually provided to the resident. | 2018-03-01 |
| 1314 | 1314 | DERBY GREEN NURSING HOME | 475048 | PO BOX 24 | DERBY | VT | 5829 | 2014-05-07 | 156 | C | 0 | 1 | 1OIY11 | Based on observation, record view and interview, the facility failed to provide residents an accurate contact number for the Division of Licensing and Protection. Findings include: 1. During the initial tour at 6:30 AM on 5/5/14, the Resident Rights posting near the main entrance was observed to have an outdated, non-working number ( [PHONE NUMBER]) for contacting the Division of Licensing and Protection (DLP) by Voice/TTY. Upon review of the facility's Admission Packet as provided by the Administrator on 5/6/14, an outdated, non-working number (802-241-2345) for contacting the Division of Licensing and Protection by Voice/TTY was listed in the document. During an interview 5/6/14 at 10:40 AM, the Administrator confirmed that the facility's posting and the Admission Packet (provided on 5/6/14) contained the non-working DLP contact information (802-241-2345) for Voice/TTY. | 2017-10-01 |
| 1403 | 1403 | THE MANOR, INC | 475057 | 577 WASHINGTON HIGHWAY | MORRISVILLE | VT | 5661 | 2014-04-02 | 156 | C | 0 | 1 | 963Y11 | Based on observation and administrative and staff interview, the facility failed to provide the correct contact number for the State Licensing and Protection Agency on posted resident rights notices and in resident admission packets as required by federal regulations. Findings include: Per observation on 4/1/14 at 10:25 AM, the facility resident rights posters on the Spruce and Elmore units had an incorrect contact number for the State Licensing and Protection Agency (SA) posted (the SA number was changed in 2011); the observation was confirmed by the facility's Director of Nursing (DON) at the same time. Additionally, per review on 4/1/14 at 12:48 PM, the facility's resident admission packet contained the same incorrect contact number for the SA, which was confirmed by the resident care services director; s/he stated that the information was corrected one week ago and s/he reported that s/he had not made the change in all of the completed admission packets, but stated s/he was changing each individual packet to include the new information prior to handing them out to new residents. | 2017-07-01 |
| 1695 | 1695 | BERLIN HEALTH & REHAB CTR | 475020 | 98 HOSPITALITY DRIVE | BARRE | VT | 5641 | 2013-06-05 | 156 | C | 0 | 1 | 6XYN11 | Based on observation and staff interview, the facility failed to prominently display written information regarding resident benefit rights and access to ombudsman and state and federal agency contact numbers. Findings include; Per observation on 6/4/13 at 4:35 PM, the facility failed to post information regarding resident rights, access to the Ombudsman and State and Federal agency contact numbers. On 6/4/13 at 4:35 PM, the Acting Facility Administrator confirmed that the above information was not posted as required. | 2016-07-01 |
| 1845 | 1845 | CRESCENT MANOR CARE CTRS | 475033 | 312 CRESCENT BLVD | BENNINGTON | VT | 5201 | 2012-12-19 | 156 | D | 0 | 1 | O6FL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that 1 resident (Resident #56) of 23 identified in the sample understood what services were included in nursing facility services under the State plan for which the resident may not be charged, those items and services that the facility offers and for which the resident may or may not be charged. The findings include: 1. Per record review, Resident #56 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#56 indicated to staff during an interview on 10/12/12 that Resident #56 thought he/she would be better off dead. The medical record also indicated that Resident #56 was verbally abusive at times and resistant to care. The medical record indicates Resident #56 sleeping for long periods of time and declining to participate in activities outside Resident #56's room. Per review of the physician's orders [REDACTED].#56 to be evaluated by Deer Oakes for the need for possible psychological services for Resident #56 related to behavior issues (verbally abusive, resistant to care, and potential signs of depression). The nurses notes indicate that the spouse of Resident #56 declined the offer for psychological services because the spouse indicated to staff that he/she did not want to pay for psychological services. Per a Physician fax order, the physician indicated to staff that the spouse would not have to pay for psychological services that they would be covered by Medicare. Per review of the comprehensive plan of care, the behavior care plan indicates to utilize psychological services as needed. Per review of the medical record there was no evidence that nursing staff or staff in the Social Services department educated the spouse of Resident #56 regarding what services are covered by Medicaid and what services are the responsibility of the resident and there was no documentation that indicates the spouse of Resident #56 was educated on the possible need for psyc… | 2016-01-01 |
| 2129 | 2129 | BERLIN HEALTH & REHAB CTR | 475020 | 98 HOSPITALITY DRIVE | BARRE | VT | 5641 | 2012-05-03 | 156 | D | 0 | 1 | RMYV11 | Based on record review and interview, the facility failed to ensure that Resident Rights were explained for one (#192) of three sampled resident records reviewed. Findings include: Per review of the clinical record for Resident #192 on 05/02/12, no signed admission contract was noted. No evidence was documented in the record that the admission paper work, including a review of the Resident Rights, had been completed or attempted. Review of the facility policy titled Admission Agreement, undated, indicated that all residents shall have on file a signed and dated admission agreement. At the time of admission, the resident (or his/her representative) must sign an Admission Agreement that outlines the services covered by the basic per diem rate, as well as any additional services requested by the resident that are not covered by the basic per diem rate. The policy does not mention the review of resident rights. No facility policy was provided that specifically addressed the provision of resident rights in writing and orally as required. Per confidential family interview, conducted on 04/30/12, one residents' responsible party relayed that no admission paper work had been completed and no one from the facility had reviewed the Resident Rights with the Resident or the family. The family member stated that there was a folder in the drawer but stated there had not been time to review it. Interview of the Admission Director on 5/2/12 at 1:06 P.M. confirmed that the paperwork, including the resident rights, had not been reviewed with the resident or family since the admission on 04/16/12. The Admission Director stated the resident requested that the family be present and s/he had been unable to make contact with the family on daily rounds. When asked if a message was left with nursing to report the family's presence or if a phone call was made to family to make an appointment, s/he stated "no". The family member was observed in the facility on three occasions between 04/30/12 and 05/03/12. The Licensed Social Worker was in… | 2015-05-01 |
| 2319 | 2319 | GILL ODD FELLOWS HOME | 475052 | 8 GILL TERRACE | LUDLOW | VT | 5149 | 2011-04-20 | 156 | B | 0 | 1 | OXNQ11 | Based on record review and staff interview for 3 residents (Residents #21, #11, and #32) the facility failed to inform the residents discharged from Medicare skilled services of their right to appeal and how to appeal. Findings include: Per record review and staff interviews, the documents given to Residents #21, #11, and #32 at the time of discharge from Medicare skilled services and presented to the surveyor upon request, contained information regarding the reason for discharge from skilled services, but did not have information regarding the right to appeal and the appeals process. This was confirmed by the facility administrator in an interview on 4/19/11 at 4:15 PM. During this interview, the Administrator and the Accounts Receivable manager stated that the notices provided were the only information provided to residents at the time of discharge from Medicare skilled services. | 2014-08-01 |
| 2410 | 2410 | THE MANOR, INC | 475057 | 577 WASHINGTON HIGHWAY | MORRISVILLE | VT | 5661 | 2011-02-09 | 156 | B | YU9Y11 | Based on staff and resident interviews (Residents #19, 101& 104), the facility failed to educate residents on their rights regarding how to access State Survey & Certification survey results, the role of the State Ombudsmen and how to contact them, and the State's 800 number to report concerns regarding abuse, neglect or misappropriation of property. Findings Include: Per interview on 2/7/11 at 2:00 PM with the Resident Council President (#19), s/he stated that s/he was not aware of the following: 1) That residents were able to access the State survey results or where they were posted, 2) Who the Ombudsman is and what their role is, and 3) That there is a State 800 number for residents to report concerns about abuse, neglect or misappropriation of resident property. After confirming the above, she stated to the surveyor, 'Please tell me where these things are because as Resident Council President, I should know.' In addition, per interview with Residents #101 & 104 on 2/8/11 between 10-10:15 AM, the residents confirmed that they were also not aware on how to access the State survey results, who the Ombudsman is and the State's 800 number for reporting resident concerns. Per interview on 2/9/11 at 2:15 PM with the Social Worker (the person assigned to help facilitate Resident Council) s/he confirmed, after reviewing Resident Council meeting minutes for the past year, that there had been no discussion/education for residents on how they could access the State survey results, what the Ombudsman's role is and how to contact them, and how to access the State's 800 number. | 2014-04-01 | ||
| 2473 | 2473 | CRESCENT MANOR CARE CTRS | 475033 | 312 CRESCENT BLVD | BENNINGTON | VT | 5201 | 2011-07-27 | 156 | C | SW6I11 | Based on observation and interview, the facility failed to prominently display written information about how to apply for or use Medicare and Medicaid benefits and information about the Medicaid Fraud Unit. On 7/25/2011 at 11:30 am, posting of resident rights and other pertinent information were found on the bulletin board outside the administrative offices. The information concerning Medicaid was outdated and also did not include how to apply for Medicaid including the address and telephone number, and the Medicaid Fraud Unit. Also, there was no information as to how to apply for Medicare. On 7/25/11 at 2:00 PM, the Administrator confirmed that these items were not posted. | 2014-02-01 | ||
| 83 | 83 | HELEN PORTER HEALTHCARE & REHAB | 475017 | 30 PORTER DRIVE | MIDDLEBURY | VT | 5753 | 2017-11-15 | 157 | B | 1 | 0 | TBWB11 | > Based on staff interview and record review, the facility failed to provide notification of room change for 2 of 2 residents in the applicable sample, Resident #2 and 3. Findings include: During interview with Resident #2, on 11/15/17, the resident stated that s/he liked his/her new roommate. The resident further stated that s/he had been moved to his/her current room a while ago and there had been a couple of different roommates. There was no evidence, during record review, that notification had been provided to Resident #2 prior to placement in current room. Further record review presents that Resident #2 was also transferred from her current room to another room on a temporary basis and then returned to the current room and there is no evidence that notification was given regarding the room change. Confirmation made by Social Service at 3:00 PM that it appears that no notification was provided to the current room. Review of the medical record for Resident #3 had a room change between 9/6 and 9/29/17 and there is no evidence that s/he had been given a notification of room change. Confirmed at 3:00 PM by the social service that notification was not given prior to the the room change. | 2020-09-01 |
| 494 | 494 | PINES REHAB & HEALTH CTR | 475044 | 601 RED VILLAGE ROAD | LYNDONVILLE | VT | 5851 | 2017-09-12 | 157 | G | 1 | 0 | 38UW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to notify the physician immediately when a significant change of physical condition was identified for 1 of 3 residents (Resident #1) in the sample reviewed. Findings include: During an interview on 9/12/17 at 2:39 PM, the LPN stated that on the evening of 8/23/17, he/she examined the right foot of Resident #1 at approximately 8:30 PM, and discovered that the tissue of the foot looked dead and there were maggots on the toe area. When asked by the surveyor whether the LPN had told anyone about this finding, the LPN stated that the night nurse coming on at 10:00 PM was advised. As confirmed in the interview, the LPN failed to notify the physician of the significantly deteriorated condition of the right foot wound, did not contact a Registered Nurse or supervisor, and did not document accurately the condition of the wound on the skin sheet or the nurse note. A faxed medical order from a podiatrist (doctor with foot specialty) was received by the facility on 8/21/17 at 3:48 PM. This medical order included specifics regarding orders for care of a wound on the right foot which was found to have wet gangrene (serious infection) and resting ischemia (lack of blood flow). The dressing order specified that the right foot wound should be washed with soap and water, patted dry, and a wet to dry dressing applied twice daily. The nursing staff did not transcribe the foot care order as per protocol, thus resulting in missed foot cleansing and dressing changes twice on 8/22/17, and once during the day of 8/23/17. Per review of a skin sheet for Resident #1, dated 8/23/17 and signed by a Licensed Practical Nurse (LPN), the LPN incorrectly transcribed a once daily treatment for [REDACTED]. A corresponding nurse note of 8/23/17 (2-10), signed by the LPN who also signed the skin sheet, documented that the foot was washed and dressing applied as per the physician's orders [REDACTED].#1 had an appoin… | 2020-09-01 |
| 551 | 551 | BEL AIRE CENTER | 475049 | 35 BEL-AIRE DRIVE | NEWPORT | VT | 5855 | 2017-08-30 | 157 | G | 1 | 1 | 0XXR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to immediately notify the physician when one resident in the applicable sample of 17 (Resident #93) had a significant change of condition. Findings include: Per review of documentation provided by the facility, Resident #93 was admitted to the facility on [DATE] for rehabilitation following hip replacement surgery. At approximately 7:30 PM on 8/15/17, Resident #93 transferred from the commode to the bed with the assistance of one Licensed Nurse Assistant (LNA). The Licensed Practical Nurse (LPN) on duty was administering medications to the roommate and reported hearing through the privacy curtain, Oh, my leg, stated by Resident #93. The LNA reported to the LPN that Resident #93 sat abruptly on the bed during the transfer. The medical record showed that the LPN examined Resident #93 and found no apparent injury. Resident #93 rated pain at that time as 4 on a scale of 0-10, with 10 being the worst possible pain. Pain medication (50 milligrams [MEDICATION NAME] orally every 6 hours as needed for pain) was administered at 7:45 PM and was documented on the Medication Administration Record (MAR) as having a positive effect. The MAR further indicated that the night nurse (an LPN) administered doses of pain medication at 1:35 AM and 6:30 AM. Significantly, the LPN documented medication effects for each of these doses bad hip pain. The LPN also documented in a night shift note (8/16/17 at 4:59 AM) that Resident #93 was in bad pain all night, did not sleep well, did not tolerate being transferred to the bedside commode, and was yelling out. The incident report and a nurse note (written at 9:09 AM) indicated that a Registered Nurse (RN) examined Resident #93 at the beginning of the day shift (7:00 AM) on 8/16/17. The RN found that Resident #93 was in pain, per non-verbal symptoms exhibited, and that the right leg had swelling and deformity. Per the incident report, the physician was notif… | 2020-09-01 |
| 747 | 747 | SAINT ALBANS HEALTHCARE AND REHABILITATION CENTER | 475021 | 596 SHELDON ROAD | SAINT ALBANS | VT | 5478 | 2016-09-13 | 157 | D | 1 | 0 | 0MLI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to inform the resident's legal guardian and representative of a significant change in [MEDICAL CONDITION] medications for 1 of 3 residents (Resident #1) prior to implementing the medication changes. Findings include: Per record review, Resident #1 was seen for a tele-psychiatric consult on 6/23/16 for evaluation of dementia with physical and verbal aggression. The psychiatrist recommended that the resident's Quetiapine (an antipsychotic medication) be stopped and the resident be started on [MEDICATION NAME] 0.5 mg twice daily (another antipsychotic medication) to increase by 0.5 mg increments every 5 days to a maximum dose of 2 mg. The psychiatrist also recommended that the resident's order for [MEDICATION NAME] (an anti-anxiety medication) be discontinued; that [MEDICATION NAME] 50 mg (an antidepressant/antianxiety medication) be offered three times daily as needed for moderate emergent agitation; that [MEDICATION NAME] 0.25 mg be offered twice daily as needed for severe emergent agitation; and that [MEDICATION NAME] (an anti-depressant medication) be started after 1 week on the scheduled [MEDICATION NAME]. On 6/23/16 at 12:38 PM, a staff nurse documented in the progress notes that, new orders obtained, message left for (responsible party) to call facility for update. On 6/23/16 the facility Nurse Practitioner (NP) documented that new orders were written based on the psychiatrist's recommendations. Per review of the MAR (Medication Administration Record) for (MONTH) (YEAR), the orders for the new [MEDICAL CONDITION] medications were implemented on 6/24/16. On 9/13/16 at 1:20 PM, the Nurse UM (Unit Manager) reported that prior to starting a new medication or [MEDICAL CONDITION] medication, a resident's family/responsible party is to be notified and a verbal consent given; a signed consent is to be obtained as soon as able. The UM confirmed that there was no evidence that Reside… | 2019-09-01 |
| 759 | 759 | BIRCHWOOD TERRACE REHAB & HEALTHCARE | 475003 | 43 STARR FARM RD | BURLINGTON | VT | 5408 | 2016-08-24 | 157 | D | 1 | 0 | 905Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interviews the facility failed to notify the family about a fall experienced by 1 of 4 residents in the sample (Resident # 3) that resulted in an injury to that resident and had the potential for requiring physician intervention. The specifics are detailed below: Per medical record review, Resident #3 was admitted to the facility on [DATE] from a local hospital with a history of frequent falls, [MEDICAL CONDITION], fractured pelvis, late onset [MEDICAL CONDITION], depression, difficulty walking and [MEDICAL CONDITION]. Resident #3 sustained falls in the facility on 7/25, 8/11 and 8/12/2016. The family was not notified of the fall on 7/25/2016, but they were told about the other 2 falls. Per review of the staff documentation and confirmed during interview with the unit manager and the facility MD, Resident # 3 was aware of the fall and so the family was not notified. The Minimum Data Set ((MDS) dated [DATE] codes the resident as severely cognitively impaired. Facility policy details informing physicians and responsible parties of any untoward events. Resident #3 had been receiving [MEDICATION NAME] and physical therapy at the time of the first fall. Per physical therapy notes during the week of 7/25/2016 Resident # 3 was noted to not be a candidate for physical therapy as her/ his pain level had increased between 7/25/2016 and 7/30/2016. On 7/30/2016 an x-ray was ordered and a note indicates that the mobile x-ray unit was not available on week-ends and the x-ray would be done on Monday, 8/1/2016. Results of the x-ray revealed a fractured right clavicle, with a sling ordered to be in place when the resident was out of bed. Pain assessments and care planning are in place and staff report that resident #3 was moved to a room that was closer to the nurses' station as she would often forget to call for help to go to the bathroom. Resident # 3 had been receiving [MEDICATION NAME], a blood thinner for an irr… | 2019-08-01 |
| 1166 | 1166 | CRESCENT MANOR CARE CTRS | 475033 | 312 CRESCENT BLVD | BENNINGTON | VT | 5201 | 2015-02-11 | 157 | D | 1 | 0 | M7JI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to notify the physician of an accident that involved injury for 1 of 5 residents reviewed, Resident #1. Findings include: Resident #1 sustained a fall on 2/4/15 at 11:50 AM, from a wheelchair, placing the resident in a prone position (face down) on the floor. resident sustained [REDACTED]. Per review of the medical record there is no evidence that the physician was notified of the fall with injury resulting. A fax prepared, by the Director of Nursing (DON), for the physician, had a hand written date of 2/4/15 and a stamp mark stating faxed with an area to write in when it was faxed, but this was blank. Another fax stamp was on the page with the date 2/6/15 written in. Per interview with the Director of Nursing on 2/11/15 at 1:25 PM, s/he stated that the fax was sent and there is a confirmation log that can be printed from the phone. The Staff Educator was unable to produce the confirmation as of 5:15 PM and stated that s/he could not provide evidence that the fax had been sent. Further confirmation was made that there is no documentation in the medical record or on the incident/accident report to support the physician was notified. On 2/11/15 at 12:03 PM, per interview with the Licensed Practical Nurse (LPN) that attended the resident immediately following the incident, that s/he had returned to the nursing station, notified the contact person and prepared a fax for the physician. Upon review of the record, there is no evidence of a fax that s/he had prepared, only the one written by the DON. This was confirmed by the staff educator at 2:09 PM on 2/11/15. | 2018-02-01 |
| 1265 | 1265 | BROOKSIDE HEALTH AND REHABILITATION | 475010 | 1200 CHRISTIAN STREET | WHITE RIVER JUNCTION | VT | 5001 | 2017-05-17 | 157 | D | 0 | 1 | IIMP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to immediately notify family and physician after an incident that resulted in injuries and required physician intervention, for 1 of 15 residents in the stage 2 sample, (Resident #21). The findings include the following: Per review of the witness statement by the Licensed Nursing Assistant (LNA), identifies on 4/28/17 at approximately 4:30 PM, Resident #21 was found to have swelling of the left side of his/her face. After the evening meal, the LNA identified that the swelling had increased. The LNA immediately reported to the nurse. The LNA also identified that the resident had eaten fish chowder, an egg sandwich and a drink of tea and apple juice for the evening meal. Per interview with the Registered Nurse (RN) on 5/17/17 at approximately 11 AM, confirmation was made that s/he notified the family on 4/29/17 at 10 AM and to the Nurse Practitioner (NP) at 11 AM on 4/29/17. Resident #21 was transferred via ambulance to the emergency roiagnom on [DATE] at approximately 12 noon for evaluation of injuries of the face and mouth, some 13.5 hours after the initial swelling was identified. | 2017-11-01 |
| 1426 | 1426 | THOMPSON HOUSE NURSING HOME | 475050 | 80 MAPLE STREET | BRATTLEBORO | VT | 5301 | 2014-07-24 | 157 | D | 0 | 1 | YY6811 | Based on record review and staff interview the facility failed to consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member upon the commencement of a new form of treatment for 1 of 3 residents, Resident #13. Findings include: 1. The facility failed to immediately inform the physician of Resident #13 of a change in the resident's physical status or a need to alter treatment significantly. Per medical record review on 07/22/14, Resident #13 was admitted to the facility with a pressure sore. Per the Nursing assessment upon admitted d, 05/27/14, notes 2 open areas. Per two nursing notes dated 06/04/14 and 06/06/14, they state the wounds ''are largely healed''. Per review of the TAR (Treatment Administration Record) no treatments were provided after 06/08/14 for skin issues. Per observation on 07/23/14 at 3:50 PM in the presence of the nurse, MDS coordinator and LNA (Licensed Nursing Assistant) two dressings were present on the resident's buttocks. When these dressings were removed, dried blood was noted on the dressings as well as red open areas on the skin. The nurse stated '' I thought the wounds were healed'' and confirmed that the family nor doctor were notified of the two pressure ulcers. Also see F-314 | 2017-06-01 |
| 1460 | 1460 | HELEN PORTER HEALTHCARE & REHAB | 475017 | 30 PORTER DRIVE | MIDDLEBURY | VT | 5753 | 2014-05-21 | 157 | E | 1 | 0 | K6IV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to immediately inform the physician of Resident #2 of a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). The findings include; 1. Per medical record review on [DATE], Resident #2 was admitted to the facility on [DATE] for short term rehabilitation after sustaining a fall and a [MEDICAL CONDITION] ([MEDICAL CONDITION]/stroke). Per record review Resident #2 also had [DIAGNOSES REDACTED]. Per the record Resident #2 was alert and oriented and able to make his/her needs known. Per review of the comprehensive care plan under the heading of Potential for Alteration in Cardiac Output created on [DATE] indicates that the nurses are to provide several interventions including check residents respiratory status and notify the physician as needed. Per review of the medical record the nurses documented a respiratory assessment each day on all three shifts. Per review of the nurse's documentation on [DATE] a respiratory assessment was completed and it was noted by the nurse that Resident #2 had fine crackles heard with inspiratory bilateral upper lobe congestion. Per the record prior to [DATE] Resident #2 had no issues or concerns related to his/her respiratory status. On [DATE] the nurses documented abnormal respiratory assessment for Resident #2 that included expiratory fine crackles. On [DATE] the nurse documented at 4:27 AM that Resident #2 had a cough, mild nasal congestion, wheezing in the upper lobes and resident was running a low grade temp of 99.0. At 9:41 AM the nurse indicated that Resident #2 had scattered rhonchi (abnormal respiratory assessment) throughout lu… | 2017-05-01 |
| 1484 | 1484 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2014-04-29 | 157 | D | 1 | 0 | 3WCP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record and policy review, the facility failed to provide a timely written notice of discharge from the facility for 1 of 3 residents. (Resident #1). Findings include: Per 4/29/14 medical record review, Resident #1 was readmitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. On 6/16/13, s/he was transferred to the hospital for symptoms of apneic breathing, a respiratory rate of 8-10 with audible gurgles and [MEDICAL CONDITION] symptoms. Per interview with the facility administrator on 4/29/14, Resident #1 has remained in the hospital since his/her transfer on 6/16/13. Per review of documents submitted by the facility administrator to the State Agency (SA) on 3/17/14, the facility issued an amended new notice of discharge to Resident #1 on 3/5/14, almost 9 months after his/her transfer to the hospital. (A first notice of discharge was issued in January 2014). Per 4/29/14 review, the facility policy, Notice of a Transfer and/or Discharge states, Our facility shall provide a resident and/or the resident's representative (sponsor) with a thirty (30)-day written notice of an impending transfer or discharge. On 4/29/14 at approximately 1:40 PM, the facility administrator confirmed that Resident #1 was not given a timely notice of discharge. (See F205 and F 206) | 2017-04-01 |
| 1617 | 1617 | ST JOHNSBURY HEALTH & REHAB | 475019 | 1248 HOSPITAL DRIVE | SAINT JOHNSBURY | VT | 5819 | 2013-11-14 | 157 | D | 1 | 0 | SD2711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to consult with a physician or notify the family regarding a significant change in medical condition for one of six residents in the sample group. (Resident #1). Findings include: Per medical record review on [DATE] and [DATE], Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the medical record, Resident #1's oxygen saturation level* for his first two days in the facility ranged from 89%-93%. He/she received supplemental oxygen by nasal cannula. On [DATE] at 7:30 AM, a staff nurse recorded Resident #1's pulse oxygen saturation at 82% (abnormal value). Per the nursing 7 AM-7 PM shift note, on [DATE] at 8 AM, Resident #1 was very groggy and unresponsive. He/she was unable to eat breakfast or take his/her medications and did not eat lunch. On [DATE] at 17:56 PM, the progress notes documented that Resident #1 was found unresponsive with no respirations and no apical pulse. His/her MD was contacted and the facility RN pronounced the resident per MD order. Per [DATE] review, the facility policy for pulse oximetry (assessing oxygen saturation), states that if the Sa02 (Sa02=oxygen saturation) is less than acceptable level for a resident's condition, notify the physician. On [DATE] at 11:50 AM, the facility Director of Nursing Services (DNS) stated that he/she would have expected Resident #1's family to be notified on [DATE] of his/her change in condition and that the resident's doctor should have been updated. Per review of the nursing progress notes, the facility DNS confirmed that there is no documentation in the medical record that Resident #1's family or physician had been notified of his/her change in condition until the resident expired. * Oxygen saturation measures the amount of oxygen in the blood; normal readings range from ,[DATE]%; values under 90% are considered low. (www.mayoclinic.com/health/hypoxemia/MY ). | 2016-11-01 |
| 1638 | 1638 | ROWAN COURT HEALTH & REHAB | 475037 | 378 PROSPECT STREET | BARRE | VT | 5641 | 2013-11-13 | 157 | D | 1 | 0 | 1J8011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews, for 1 of 6 sampled residents, (Resident #3) the facility failed to provide written notification to the resident and the resident's legal representative when there is a change in resident rights policy. The findings include: Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Per interview, Resident #3's DPOA (Durable Power of Attorney) has been permitted to audio tape care plan meetings for the past one and one-half years. This initiative was permitted by past administration for the purpose of sharing information with Resident #3 in a non threatening environment, with noise control and no time constraints. Per interview on 11/13/13 @10:07 AM with the Social Service Director and the Nursing Home Administrator (NHA), confirmation was made that Resident #3's DPOA was informed of the Surveillance policy during a meeting with Vice President of Operations and NHA. During the meeting the DPOA was informed the practice of audio taping was no longer allowed under current administration. Per medical record review, there is no evidence in the Social Service Progress Notes or in the Resident's Care Plan indicating that audio taping is no longer allowed for the purposes of sharing information with Resident #3. Per interview on 11/13/13 @ 10:07 AM with the NHA, s/he confirms that Resident #3's DPOA was not provided with any written notice in advance of the change in policy or in instituting the policy that originated in the year 2000 (Using Surveillance Equipment). Per interview on 11/13/13 @ 10:07 AM with the NHA, s/he confirms that there is no documentation to provide evidence that a meeting took place. | 2016-11-01 |
| 1762 | 1762 | ROWAN COURT HEALTH & REHAB | 475037 | 378 PROSPECT STREET | BARRE | VT | 5641 | 2013-05-15 | 157 | J | 1 | 0 | WS7Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to notify the physician of a need to alter treatment significantly for one of four residents in the sample (Resident #1). Findings include: 1. Per record review on 5/14/13, Resident #1 was admitted to the facility on [DATE] from hospital for short term rehabilitation after having fallen at home and sustaining a chest injury. S/he had been living at home with home health services and help from family, and had recently had a ramp built onto the home. Upon nursing home admission, [DIAGNOSES REDACTED]. The medical record included a nursing plan of care dated 4/30/13. This admission plan of care included the following section: Fluid volume deficit related to: azotemia/dementia: assess for dehydration, monitor intake and output, encourage PO (by mouth) fluids, and medications as ordered. The Registered Dietician (RD) conducted an admission nutrition assessment on 5/1/13. This assessment estimated the fluid intake needs of Resident #1 as 1,500 cc to 1,700 cc (1 cc=1 milliliter) per day. Fluid intake records provided by the facility documented the following daily fluid intake totals: 4/30/13 120 cc; 5/1/13 420 cc; 5/2/13 240 cc; 5/3/13 420 cc; 5/4/13 480 cc; 5/5/13 0/no entry. On 5/3/13, Resident #1 was noted in day shift nursing progress notes as having difficulty keeping in the mouth the crushed medications taken with pudding and water. On 5/4/13, the day shift nursing progress notes documented that Resident #1 was observed having difficulty swallowing foods and liquid, with frequent coughing. The facility did obtain on 5/2/13 an evaluation by the Speech Language Pathologist (SLP) who recommended treatment and staff assistance with eating and drinking. There was evidence that the dietary slip and care plan changed to staff assistance from independent eating. However, on 5/15/13 neither the charge nurse, nor the Director of Nursing (DON), nor the physician's office could provide evide… | 2016-05-01 |
| 1838 | 1838 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2013-01-30 | 157 | D | 1 | 0 | MPUG11 | br>Based on record review and staff interview, the facility failed to immediately inform the resident's legal representative of a decision to transfer Resident #1 from the facility to the emergency room . Findings include: Per record review, the incident note states that the resident's daughter was called on 12/25/2012 at 11:40 PM and a message left that a fall had occurred and to call back. The note states that the resident was transferred to the emergency room (ER) via ambulance at 12:40 AM. There was no additional note stating that the daughter was notified that resident had been transferred to the ER. The nurses notes in the resident record indicate that a call was placed to the resident's daughter on 12/25/2012 at 11:40 PM to let her know that the resident had fallen and request a call back. It does not reflect whether or not the message stated that the resident was being transferred to the ER. In an interview at 3:14 PM the nurse who wrote the note stated that s/he did state, in the first call, that the resident might be transferred to the ER and that s/he did not state that the resident was OK. S/he also stated s/he believed that the nurse relieving him/her would notify the family of the resident's transfer to the ER after the decision was made to send her/him out. There is no evidence that this call was made per the Director of Nursing Services in an interview at 3:30 PM on 01/30/2013. | 2016-01-01 |
| 1871 | 1871 | REDSTONE VILLA | 475055 | 7 FOREST HILL DRIVE | ST ALBANS | VT | 5478 | 2013-01-03 | 157 | D | 1 | 0 | 12H711 | br>Based upon interview and record review, the facility failed to document that the resident or legal representative was notified when there was a room change for 1 of 8 residents in the applicable sample. (Resident #1). Finding includes: 1. Per record review and confirmed during an interview with the Director of Nursing (DNS) on 1/3/13 at 10:50 AM, Resident #1 was moved from the first floor to the second floor on 12/18/12 and there is no documentation that the family was notified of the room change in either the electronic or hard copy medical record. | 2016-01-01 |
| 1919 | 1919 | SAINT ALBANS HEALTHCARE AND REHABILITATION CENTER | 475021 | 596 SHELDON ROAD | SAINT ALBANS | VT | 5478 | 2012-10-03 | 157 | D | 1 | 0 | JOSX11 | Based on staff interview and record review, the facility failed to immediately inform the physician and responsible family member after 1 of 4 residents in the total sample was observed ingesting a potentially harmful non-food substance. (Resident #1). Findings include: Per record review on 10/2/12, a nurse found Resident #1 drinking aftershave lotion on 9/4/12 and there was no evidence of notification of the incident to the physician and the responsible family member by the nurse and there was no evidence of monitoring and assessment to determine if the resident (who has dementia) was harmed by ingestion of this non-food substance. Per progress notes dated 9/2/12 at 2223 hours, the nurse wrote this nurse checking on resident and found (him/her) drinking aftershave so nurse threw away aftershave. There was no documented assessment nor evidence of monitoring the resident after the incident. No incident report was completed per interview with the Director of Nurses (DNS). The facility's policy entitled Accidents, Incidents and Adverse Events reviewed at 4 PM with the DNS stated All accidents, incidents or adverse events occurring on Genesis Healthcare Center premises should be reported, reviewed, and, if indicated, investigated without fear or reprisal. An incident is defined as any occurrence not consistent with the routine operation of the Center or normal care of the resident/patient. The DNS confirmed at 4 PM that an incident report should have been completed by the nurse, that the physician and family should have been notified and that there should be documented evidence of assessment and on-going monitoring of the resident after the ingestion of the aftershave. Per review of all progress notes from 9/5/12 - 9/12/12 at 1137 hours, there was no mention of the incident regarding ingestion of the aftershave on 9/4/12. The notes reviewed included a provider summary/assessment of a visit on 9/10/12 and notes from a care plan meeting documented on 9/12/12. Refer also to F281 | 2015-10-01 |
| 1958 | 1958 | VERMONT VETERANS' HOME | 475032 | 325 NORTH STREET | BENNINGTON | VT | 5201 | 2012-09-05 | 157 | D | 1 | 0 | CT6P11 | Based on record review and interview the facility failed to consult with the physician regarding a change in health status for one resident. This affected one (Resident #1) of 14 sampled residents. Findings include: 1. Per record review on 09/04/12 at 11:20 A.M., Resident #1 had a change in condition documented on 06/08/12 that necessitated notification of the physician and required the Resident to receive wound care. The SBAR (situation, background, assessment, reporting) form dated 06/08/12 shows that the nurse attempted to reach the physician twice without success and applied a dressing according to the standing orders. There is no evidence that the physician was consulted about the specific wound and aware of the wound until 06/18/12. Per interview on 09/05/12 at 10:30 A.M., the physician stated that s/he had ''no recollection of receiving a message about this resident. Per interview at 3:30 P.M., the Assistant Director of Nursing, confirmed the physician was not consulted immediately regarding the change in health status. . | 2015-09-01 |
| 2019 | 2019 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2012-04-12 | 157 | D | 1 | 0 | 0DC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview, the facility failed to ensure the physician and responsible party were notified of the development of an additional pressure ulcer until three days after it was first documented. This affected one (Resident #4) of four sampled resident records reviewed. Findings include: Per clinical record review on 03/21/12, Resident #4 was admitted on [DATE] with one open area noted to the right buttocks measuring 0.5 centimeters in diameter. The Nursing Admission assessment dated [DATE] also indicated the left buttock was reddened and intact. The Nurse's Notes dated 03/05/12, and timed 7:00 A.M. to 7:00 P.M., indicated the dressing was changed to the right buttocks open area. The note did not include a description of the area at that time. The Nurse's Notes dated 03/06/12 at 2:00 P.M., indicated Resident #4 had two open areas on buttocks. The coccyx measured 0.4 centimeters in diameter and the left gluteal fold measured 0.3 centimeters in diameter. The Weekly Pressure Ulcer Flow Sheet indicated that the initial assessment of the pressure ulcers by the Wound Nurse was completed on 03/06/12 and two pressure ulcers were present in close proximity on the right buttock at that time. A Nurse's Note dated 03/09/12, 7:00 A.M. to 7:00 P.M., indicated that the dressing was changed secondary to loose stools and the open areas were not described. On 03/09/12 at 1:30 P.M., an entry indicated the responsible party was notified of a new pressure ulcer noted by the wound care nurse on 03/09/12 and at 1:45 P.M. the Nurse's Note indicated the physician was notified of the development of a new stage II (partial thickness) ulcer located in close proximity to the stage II ulcer noted on admission. Orders for treatment were noted at that time. The Nurse's Notes revealed no indication that the physician or responsible party was notified of the development of additional skin breakdown between 03/06/12 and 03/09/12. Interview of the … | 2015-08-01 |
| 2027 | 2027 | CENTERS FOR LIVING AND REHAB | 475029 | 160 HOSPITAL DRIVE | BENNINGTON | VT | 5201 | 2012-08-02 | 157 | D | 1 | 0 | IE4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the physician in a change of condition for 1 patient in the applicable sample. (Patient # 1) Findings include: Per review of nursing documentation for Resident #1 on the evening shift of 6/10/12 at 21:17 (9:17 P.M.), the staff nurse documents for Resident #1's 'sensory assessment' under the heading nose/sinuses: 'Bleeding, x 3 this shift.' There was no further documentation related to the bleeding including follow-up monitoring and/or observation on his/her shift. In addition, the staff nurse failed to communicate this change in the resident's condition to the physician and confirmed s/he was aware that the resident was on long-term anticoagulant therapy and that bleeding was a side effect. The next morning, on 6/11/12 at 7:40 AM the ambulance was called to transport Resident #1 to the Emergency Department because of a nosebleed. At 14:02 (2:02 P.M.) the staff nurse documents: 'Resident sent to ER per MD re nose bleed profuse and unable to stop and respirations very moist at 0730. Resident returned at 11:50 nose bleeding again and returned to ER where (s/he) was admitted .' Per interview with the staff nurse responsible for caring for Resident #1 during the evening of 6/10/12, s/he confirmed on 6/19/12 at 4:15 P.M. that the physician had not been called to report the resident's three nosebleeds although s/he was aware that the resident had been on long-term anti-coagulant therapy and that bleeding is a side effect of anti-coagulant therapy.* *Mosby's Nursing Drug Reference, 2012. Page 10&11. [MEDICATION NAME]: Assess for bleeding gums, petechiae, ecchymosis, hematuria. Report signs of bleeding: gums, under skin, urine and stools. | 2015-08-01 |
| 2073 | 2073 | ST JOHNSBURY HEALTH & REHAB | 475019 | 1248 HOSPITAL DRIVE | SAINT JOHNSBURY | VT | 5819 | 2012-03-14 | 157 | D | 1 | 0 | 5ZH911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately notify one applicable resident's (Resident #1) physician of a change in condition. Findings include: Per record review on 03/14/12 at 10:00 AM, Resident #1 had a change in condition on 03/10/12 that necessitated notification of the physician for an evaluation at the emergency room . Per the nursing note of 03/11/12 , (a late entry for 03/10/12 ) nursing states "if these treatments (new medication orders) didn't work maybe a trip to a hospital would be needed. At 1700 (5:00 PM) family summons nursing to room and stated the resident isn't any better and maybe s/he should go to the hospital. (Nursing) agrees and preparations made for transfer...called EMS (Emergency Medical Services)". Documentation shows that at 3:45 PM, prior to the decision to transfer to the hospital, the physician gave telephone orders for an inhaled medication for treatment of [REDACTED]. Per interview on 03/14/12 at 1:30 PM the Weekend Supervisor stated that while talking to the on-call physician that day, it was discussed that 'maybe the resident might have to go to the hospital'. The weekend supervisor confirmed at 4:00 PM that the physician was not immediately notified about the transfer to the ER. | 2015-07-01 |
| 2199 | 2199 | CEDAR HILL HEALTH CARE CENTER | 475046 | 49 CEDAR HILL DRIVE | WINDSOR | VT | 5089 | 2012-06-27 | 157 | D | 0 | 1 | JDUP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the primary physician of an increase in combative behaviors and agitation for 1 resident of 31 (Resident #35) in the Stage 2 sample. The findings include: 1. Per review of the medical record, Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per the psychological evaluation dated 4/13/12, the evaluation indicates that Resident #35 has a history of dementia and was seen for evaluation of the dementia and behavior problems. The evaluation indicates that Resident #35 has a history of striking out with care. Per review of the nurse's notes, Resident #35 was medicated with an as needed (PRN) dose of [MEDICATION NAME] for combative behaviors and agitation on 5/11, 5/12, 5/23, 5/24, 5/25, 5/26, 5/27, 5/28 and 5/31. Per review of the nurse's notes, the notes indicate that Resident #35 has sustained bruising as a result of his/her combative behavior. Per review of the comprehensive care plan titled "At risk for untoward effects of [MEDICATION NAME], [MEDICAL CONDITION] drug use" initiated on 12/11/11, the care plan indicates that "if resident presents with increased combative behaviors then report to physician". Per review of the physician notes, there was no documentation that the physician was notified of any increase in combative behaviors from 5/2/12 until 6/10/12 when the physician was notified via fax. Per review of the facility's policy titled "Problematic Behavior Management", the policy indicates "the staff will identify, document and inform the physician about an individual's mental status, behavior, and cognition." Per interview with the DNS on 6/27/12 at 1:09 PM, he/she confirmed that no physician had been informed from 5/2/12 to 6/10/12 of Resident #35's increase in behaviors, and the DNS confirmed that the resident should have been re-assessed for the increase in behaviors. | 2015-03-01 |
| 2267 | 2267 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2011-06-02 | 157 | D | 1 | 0 | OTVM11 | Based upon interview and record review, the facility failed to immediately notify 1 applicable resident's physician and legal representative of a clinical complication when the Nasogastric (NG) tube, which is used to feed the resident, became blocked and needed to be replaced. (Resident #1). Findings include: Per interview on 6/1/11 at 3:40 PM, Resident #1's legal guardian stated the resident's "NG tube came out on 4/23/11 at 3:30 PM and she/he was not notified until 4/24/11 at 6:00 AM". Per record review and confirmed during an interview with the Director of Nursing (DNS) on 6/1/11 at 4:26 PM, Resident #1's NG Tube became blocked and was replaced by nursing staff on 4/23/11 at 1530 (3:30 PM), the physician was not notified until 4/23/11 at 2300 (11:00 PM), and the legal guardian was not notified until 4/24/11 at 0600 (6:00 AM). | 2014-10-01 |
| 2271 | 2271 | CENTERS FOR LIVING AND REHAB | 475029 | 160 HOSPITAL DRIVE | BENNINGTON | VT | 5201 | 2011-06-01 | 157 | D | 1 | 0 | 16J411 | Based on interviews and record reviews, the facility failed to inform family members of a discontinuation of treatment for 2 of 11 Residents in the sample (Residents #1 and #2). Findings include: 1. Per record review on 6/1/11, the facility failed to immediately inform Resident #1's family when the resident's restorative care plan to treat contractures was suspended for an indefinite period of time on 1/27/11. The family was not apprised of the changes until they inquired about care issues on 3/2/11. The lack of notice to the family was confirmed during interviews with the Administrator at 10:15 AM and the Unit Manager at 12:55 PM on 6/1/11. 2. Per record review on 6/1/11, the facility did not notify Resident #2's family when his/her restorative nursing program was discontinued on 2/1/11. This was confirmed by the Unit Manager (UM) during a 1:58 PM interview on 6/1/11. | 2014-10-01 |
| 2290 | 2290 | KINDRED TRANSITIONAL CARE & REHAB BIRCHWOOD TER | 475003 | 43 STARR FARM RD | BURLINGTON | VT | 5408 | 2011-05-24 | 157 | D | 1 | 0 | XL5K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify 1 of 17 sampled resident's (Resident #1) family of a change in condition. Findings include: Per record review on 5/24/11 at 8:00 AM, Resident #1 had a change in condition necessitating transfer to a hospital on [DATE]. There was no evidence in the clinical record that the family was notified. During a 5/24/11, 2:15 PM interview with the Director of Nursing Services (DNS), the DNS confirmed that the family was not notified of Resident #1's transfer to a hospital. | 2014-09-01 |
| 2293 | 2293 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2011-05-09 | 157 | D | 1 | 0 | ZDVQ11 | Based upon interview and record review, the facility failed to notify the physician and/or legal representative concerning allegations of resident to resident incidents, as stated in facility policy, involving 3 residents. (Residents #1, #2, #3). Findings include: 1. Per record review and confirmed with the Assistant Director of Nursing (ADNS) on 5/9/11 at 11:30 AM, the physician for Resident #1 was not notified concerning an alleged inappropriate sexual contact made to Resident #1 by Resident #2 on 1/25/11. In addition, the ADNS confirmed that per the Accidents and Incidents Investigating and Reporting Policy, the nurse supervisor and/or charge nurse shall inform the physician of the incident. 2. Per record review and confirmed with the ADNS on 5/9/11 at 12:10 PM, the physician for Resident #2 was not notified concerning Resident #2's alleged inappropriate sexual contact to Resident #1 on 1/25/11. 3. Per record review and confirmed with ADNS on 5/9/11 at 1:24 PM, the physician and legal representative of Resident #3 were not notified of an alleged staff to resident physical abuse to Resident #3 on 1/18/11. | 2014-09-01 |
| 2314 | 2314 | STARR FARM NURSING CENTER | 475030 | 98 STARR FARM RD | BURLINGTON | VT | 5408 | 2011-04-14 | 157 | D | 1 | 0 | MBKR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify Resident # 1's family of a change in condition. Findings include: Per record review on 4/14/11 at 8:45 A.M., Resident #1 had a change in condition on 4/7/11 that necessitated notification of the on-call physician. The family of Resident #1 was not notified of this change in condition. Resident #1 required transfer to the hospital on [DATE] and was admitted at that time for medical treatment. In a 4/14/11 interview at 10:05 A.M., the Facility Executive Director stated that it is facility policy to notify family of any change in condition, regardless of any changes in treatment. The Executive Director confirmed that the family was not notified of Resident #1's 4/7/11 change in condition. | 2014-08-01 |
| 2328 | 2328 | GILL ODD FELLOWS HOME | 475052 | 8 GILL TERRACE | LUDLOW | VT | 5149 | 2011-04-20 | 157 | E | 1 | 0 | OXNQ11 | Based on record review and interview, the home failed to notify the physician and the resident's family / legal representative following a change in 1 resident's mental/psychosocial condition, manifested by several resident to resident issues involving Resident #15. Findings include: 1. Per record review on 4/18/11, Resident #15's physician and / or family was not notified of incidents of sexual aggression in a timely manner. The record indicated that this resident had engaged in inappropriate sexual advances toward other residents and staff on 11/29/10, 1/13/11, 3/25/11, 3/26/11 and 3/31/11 with indication that the physician and family was notified only on 3/31/11. Additional incidents of sexual aggression occurred on 4/6/11 and 4/16/11 with no indication of physician or family notifications. During interview on 4/20/11, the Director of Nursing confirmed that the record contained only 1 instance of physician and family notification on 3/31/11 regarding the resident's behavior issues. | 2014-08-01 |
| 2458 | 2458 | PINE HEIGHTS AT BRATTLEBORO CENTER FOR NURSING & R | 475023 | 187 OAK GROVE AVENUE | BRATTLEBORO | VT | 5301 | 2010-10-27 | 157 | D | KDRM11 | Based on staff interview and record review, the facility failed to consult with the resident's physician and notify the resident's legal representative regarding a significant change in the resident's physical status for one resident in the applicable sample. (Resident #1) Findings include: 1. The facility did not inform the resident's physician and family of the failure of a skin condition to improve with treatment, as well as to report the worsening status of the skin condition after a prescribed three month treatment regimen was completed for Resident #1. Per review of the resident's Nurses Notes (NN), the resident had a recurrent skin condition requiring treatment and referral to a medical specialist on 7/20/10. A three month course of therapy was prescribed and was given as ordered by the specialist during which no improvement was documented by nursing staff. Confirmed during interview with the Director of Nursing Service (DNS) and the Wound/Skin Care Nurse on 10/27/10 at 1:58 PM, the resident's skin condition did not improve with treatment and began to worsen further after the completion of the ordered treatment regimen on 10/8/10. The Wound/Skin Care Nurse stated during this interview: "It was my responsibility to inform the resident's physician and family about the failure of the treatment to improve the skin. I should have also informed them when the condition began to worsen." | 2014-02-01 | ||
| 2512 | 2512 | GREENSBORO NURSING HOME | 475043 | 47 MAGGIE'S POND ROAD | GREENSBORO | VT | 5841 | 2010-09-24 | 157 | D | FSI211 | Based upon interview and record review, the facility failed to inform the physician following a physical altercation between two residents (#1, #2). Findings include: 1. Per per medical record review on 9/24/10 for Resident #2, the 8/9/10 nursing note does not contain documentation that the physician was notified that Resident #2 hit Resident #1 on the back without provocation. In addition, the 8/9/10 Facility Incident Report Form does not contain documentation the physician was notified of the incident that occurred between Resident #1 and Resident #2 on that date. Per interview on 9/24/10 at 11:05 AM, the DNS (Director of Nursing Services) confirmed the physician was not notified that Resident #2 hit Resident #1 without provocation. 2. Per record review on 9/24/10 for Resident #1, the 8/9/10 nursing note does not contain documentation that the physician was notified that Resident #1 was hit on back with no injuries resulting by Resident #2. In addition, the 8/9/10 Facility Incident Report Form does not contain documentation the physician was notified of the incident that occurred between Resident #1 and Resident #2 on that date. Per interview on 9/24/10 at 11:05 AM, the DNS confirmed the physician was not notified that Resident #1 was hit on the back with no injuries resulting by Resident #2. | 2014-01-01 | ||
| 854 | 854 | BENNINGTON HEALTH & REHAB | 475027 | 2 BLACKBERRY LANE | BENNINGTON | VT | 5201 | 2016-05-02 | 159 | B | 1 | 0 | PHFS11 | > Based on staff interviews and record review, the facility failed to have written agreement to safeguard and manage an account for the personal funds for 1 of 4 residents in the survey sample, Resident #1. The facility also failed to provide quarterly statements to 1 of 4 residents in the sample, Resident #2. The facility also failed to have personal resident funds readily accessible to residents. Findings include: 1.) Review of agreements that the facility provides to residents for whom they manage personal funds accounts presented that one of four residents, Resident #1, did not have a signed agreement. The business office manager confirmed at 12:31 PM that the residents sign an agreement for managing of funds, but there is no evidence that Resident #1 has such a signed document. S/he further confirmed that the facility does manage the personal funds account for Resident #1. 2.) Review of quarterly statements for the four sampled residents presented that Resident #2 has quarterly statements that are sent to his/her son instead of to him/her. The resident is his/her own guarantor and there is no evidence that s/he has a financial Power of Attorney. The resident stated in an interview at 2:00 PM that s/he handles his/her own money and that his/her son is not responsible for it. The quarterly statement according to the business office manager at 12:26 PM, is not being given to the resident but is being sent to the family member. The Unit Manager confirmed at 2:23 PM that the medical record indicates that the resident is the guarantor and there is no evidence that the family member is the legal representative for finances. 3.) Per interview with the Business Office Manager, personal resident funds are not available after hours and on weekends. Per interview with Resident #2, s/he stated that s/he did not think they could get any money on Sundays. The facility did not have funds available upon request and had to wait for corporate to send a check for Resident #2. | 2019-05-01 |
| 983 | 983 | PINES REHAB & HEALTH CTR | 475044 | 601 RED VILLAGE ROAD | LYNDONVILLE | VT | 5851 | 2015-12-09 | 159 | C | 0 | 1 | JQPS11 | Based on interviews with resident families and facility staff, and review of personal funds accounts, the facility failed to provide written quarterly statements to residents or legal representatives for 49 of 49 residents who have a personal funds account with the facility. The specifics are as follows: Per review of the facility checking accounting system used for resident personal funds accounts, there is no evidence to reflect that quarterly statements were issued to either residents or their legal representatives for the last year. This is confirmed by the Director of Social Services during interviews on 12/08/2015 and 12/09/2015. S/he reports that residents or their legal guardians are notified verbally when money is needed to be added to the individual accounts but that s/he has not sent out written statements during the past year. Confirmation that no written statements were sent to residents was also obtained during a family interview during stage 1 of the survey process on 12/07/2015. Family reported never receiving a statement that indicates how much money is in the personal funds account but that s/he is told when money needs to be added for incidentals. | 2018-11-01 |
| 1467 | 1467 | NEWPORT HEALTH CARE CENTER | 475026 | 148 PROUTY DRIVE | NEWPORT | VT | 5855 | 2014-02-26 | 159 | B | 0 | 1 | 6DTC11 | Based on resident and staff interviews, the facility failed to ensure that 2 of 22 residents in the stage two sample have ready and reasonable access to their personal funds including on weekends (Resident #41 and Resident #56). Findings include: Per interview on 2/24/14 at 11:24 AM, Resident # 56 reported that the business office is closed on Saturday and Sunday, so (I) can't get money on the weekend. I make sure that I get money when they are open so I will have it when I need it. On 2/25/14 at 8:51 AM, Resident # 41 reported that s/he could not access personal funds on the weekend and has to get money on Friday if (s/he) thinks (s/he will) need it for the weekend. Per interview on 2/25/14 at 12:53 PM, the staff member in charge of personal funds reported that resident funds are available when s/he is working from 8-4 PM Monday-Friday; on weekends, an envelope with approximately $30 is available at the nurses' station. Per 2/25/14 interview at 1:00 PM, the facility nursing supervisor stated s/he was not sure how to access resident funds on the weekend. Per 2/25/14 interview at 1:01 PM, a west wing staff nurse, reported that since the first of the year, (resident) funds have not been brought to the unit for weekends. On 2/25/14 at 1:05 PM, an east wing nurse reported that there used to be an envelope with $30 kept in the medication cart, but it's been at least a year since s/he had funds available on the cart. Per 2/25/14 interview at 2:44 PM, the Director of Nursing (DNS) stated that s/he did not know that there was an envelope with money on the medication cart (for resident funds) or that it was no longer being put on the cart and stated s/he would call the person in charge of the funds for access on weekends. On 2/26/14 at 12:48 PM, the facility nursing supervisor confirmed that s/he was not aware of how residents could access personal funds on the weekends and confirmed that the funds need to be available to residents 7 days per week. | 2017-05-01 |
| 1696 | 1696 | BERLIN HEALTH & REHAB CTR | 475020 | 98 HOSPITALITY DRIVE | BARRE | VT | 5641 | 2013-06-05 | 159 | B | 0 | 1 | 6XYN11 | Based on staff interviews and reviews of facility policies and admission packet contents, the facility failed to provide residents with access to their personal funds whenever needed. Findings include: Per review of the facility policies and the information that is given to residents and their families upon admission, personal funds are only accessible during business hours. This is also confirmed during a family interview for Resident # 76 during stage 1 of the survey process on 06/04/2013. Per interview with the Accounting office staff on 06/04/2013 at 1:56 PM the facility manages personal funds accounts for 66 of the residents currently residing in the home. S/he reports that residents have access to their funds only during regular business hours but need to make arrangements in advance if money will be needed during the evening hours or on the week-ends. | 2016-07-01 |
| 1729 | 1729 | ROWAN COURT HEALTH & REHAB | 475037 | 378 PROSPECT STREET | BARRE | VT | 5641 | 2013-06-05 | 159 | B | 1 | 0 | JZ3611 | Based on resident and staff interview, the facility does not have a current system to ensure that residents have ready access to their personal funds held by the facility on weekends and some Holidays. This has the potential to affect all residents who request that the facility manage their personal funds accounts. Per resident interviews during Stage 1 of the survey on 6/3/13 and 6/4/13, 2 residents reported a lack of access to personal funds on weekends. Per interview on 6/5/13 at 11:05 AM, staff from the Business Office confirmed that there is no current system to assure residents have ready access to their funds on weekends and some Holidays. | 2016-06-01 |
| 2301 | 2301 | MAPLE LANE NURSING HOME | 475042 | 60 MAPLE LANE | BARTON | VT | 5822 | 2011-06-29 | 159 | B | 0 | 1 | 33IM11 | Based on interview with one resident in the sample (Resident #24) & staff interviews, the facility failed to ensure that the residents of the facility have ready and reasonable access to their personal funds including weekends. Findings include: Per interview with Resident # 24 during Phase 1 of the survey, s/he reported that s/he could not access their personal funds on the weekends and 'only if s/he asked ahead of time on Fridays.' Per interview on 6/29/11 at 2:40 P.M., with the staff member who was identified by the facility as the person who manages the personal funds account(s) for the residents, s/he confirmed that personal funds were not available to the residents on weekends. S/he stated that residents have access to their money 'Monday through Friday from 7 A.M. to 4:30 P.M.' and that money was not available on weekends because s/he was 'not there on weekends.' . | 2014-09-01 |
| 2320 | 2320 | GILL ODD FELLOWS HOME | 475052 | 8 GILL TERRACE | LUDLOW | VT | 5149 | 2011-04-20 | 159 | C | 0 | 1 | OXNQ11 | Based on interview and record review, the facility failed to hold funds in excess of $50 in an interest bearing account that is separate from any of the facility's operating accounts or provide quarterly statements for 10 of 10 residents with a positive balance in their resident fund accounts. (Residents # 28, 17, 7, 3, 14, 36, 25, 34, 31, 18 & 2) Findings include: Per interview with Resident #7 on the morning of 4/20/11, the resident has not been receiving quarterly statements on his facility resident funds account. During interview later the same morning, the business office manager and the administrator confirmed that they had not been providing residents with quarterly statements for fund accounts since June of 2010. In addition, 7 of the resident fund balances reviewed were over $50.00 and there was no evidence that these funds were presently accruing interest, per regulatory requirements. In reviewing the total balance of the money in the resident fund account, it was noted that the total amount listed exceeded the total amount of the resident fund balances by several thousand dollars and the administrator and the business office manager were not able to explain the discrepancy. | 2014-08-01 |
| 2361 | 2361 | VERMONT VETERANS' HOME | 475032 | 325 NORTH STREET | BENNINGTON | VT | 5201 | 2011-05-04 | 160 | B | 0 | 1 | 888811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review the facility failed to convey the remaining funds and an accounting of the funds for three applicable deceased Residents (R#1, R#2, and R#3) within 30 days of their death. Findings include: Per review of three records of deceased residents (R#1, R#2, R#3 ) the time frame for return of funds and a final accounting exceeded thirty days. For two of the three residents the funds were returned in forty-seven days and for the third resident funds were returned in forty-three days. In an interview with the Administrator on [DATE] at 12:05 PM she stated that the facility practice is to return funds for deceased residents at the end of the following month, which may exceed thirty days. This was confirmed with a representative of the Billing Dept at 12:10 PM on [DATE]. | 2014-06-01 |
| 960 | 960 | GREEN MOUNTAIN NURSING AND REHABILITATION | 475040 | 475 ETHAN ALLEN AVENUE | COLCHESTER | VT | 5446 | 2016-04-06 | 164 | E | 0 | 1 | M3QB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure that all information contained in residents' medical records was stored in a manner that ensured that confidentiality of the information was maintained for closed records dated from 2010-2015. The findings include: Per direct observation beginning on the morning of 4/4/16, approximately 78 cardboard boxes of closed medical records [REDACTED]. Per observation, not all of the boxes were covered and names of some of former residents were visible in these boxes. There were also medical records, including probate court correspondences, physician orders [REDACTED]. On 4/15/16 at 7:30 AM, two members of the contracted housekeeping service were observed alone in the Cave (with the stored records) sweeping the floor. At 7:38 AM, the contracted supervisor of housekeeping and laundry services reported that maintenance staff unlocks the door to the room so that housekeeping can sweep the floor, about every other day. S/he reported that the housekeeper is alone in the room doing the cleaning. S/he also reported that the Cave is used for staff meetings. On 4/5/16 at 1:26 PM, the facility administrator reported that there had been a leaking pipe in the medical record room a couple of months ago and that the boxes of medical records were moved to the Cave. She confirmed the surveyor observations as listed above and that resident medical information was visible. The administrator confirmed that staff meetings are held in the room and that housekeeping staff are not authorized to have access to medical records. The following policies were reviewed and confirmed with the administrator at the time of the interview: 1. Location and Storage of Medical Records (from the Operational Policy and Procedure Manual; adoption date 5/2013) states under Policy Interpretation and Implementation, 2. Medical records are stored in a locked room and protected from fire, water damage, insects and theft. 2. Th… | 2019-01-01 |
| 1013 | 1013 | FRANKLIN COUNTY REHAB CENTER LLC | 475047 | 110 FAIRFAX ROAD | ST ALBANS | VT | 5478 | 2015-04-07 | 164 | B | 0 | 1 | ZO1D11 | Based on observation and staff interview, the facility failed to ensure that medical records were stored in a manner that kept them secure from unauthorized access. Findings include: Per observation over 2 days of survey (4/6/15 - 4/7/15), clinical records for the Four Seasons Unit were located in the hallway in front of the nurses station. Residents from all units and visitors were observed passing by the records. There were 18 records in the rack at the time of the observations. Per interview with the Director of Nurses (DON) on 4/7/15 at 2:10 PM, the records have been in that location since the facility opened. The DNS confirmed that the records were accessible to residents and visitors. | 2018-09-01 |
| 1266 | 1266 | BROOKSIDE HEALTH AND REHABILITATION | 475010 | 1200 CHRISTIAN STREET | WHITE RIVER JUNCTION | VT | 5001 | 2017-05-17 | 164 | E | 0 | 1 | IIMP11 | Based on observation, record review and staff interview, the facility failed to keep secure the confidential, personal resident records for five residents when they attached the survey Resident Identifier documents to posted survey results dated 8/23/16 (Resident #3) and 3/8/17 (Residents #1, 2, 3, 4). Findings include: During the initial tour of the facility on 5/15/17 at approximately 9:45 AM, the surveyor examined the binder containing survey results which was accessible to the public and residents, as required. For two surveys in the binder, dated 8/23/16 and 3/8/17, the facility had left attached to the survey results report the Resident Identifier documents. The Resident Identifier provides a reference which names the subjects of the deficiency statements who are otherwise given a number. The number assigned to each resident is meant to protect their confidentiality and the corresponding names should not be shared publicly. On 5/15/17 at 10:00 AM, the Human Resources Director confirmed that the binder which displays survey results did contain the two Resident Identifier documents corresponding to the deficiency statements dated 8/23/16 and 3/8/17. This potentially identified to the public and all residents of the facility the five residents who were the subjects of the two deficiency statements, thereby violating their right to privacy and confidentiality. | 2017-11-01 |
| 1282 | 1282 | CRESCENT MANOR CARE CTRS | 475033 | 312 CRESCENT BLVD | BENNINGTON | VT | 5201 | 2014-11-13 | 164 | D | 1 | 0 | SUV211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review the the facility failed assure personal privacy is afforded to all residents and failed to contact the legal representative of one resident to acquire consent to take a video of the resident using a staff member's phone (R#1). Findings include: Per observation and record review, R#1 resides in the facility on the [MEDICAL CONDITION]'s Disease Unit. S/he was admitted to the facility on [DATE] and had a consent for photographs for publicity, on the bulletin boards, on facility literature and for use of her/his name. This consent was signed by the resident's Legal Guardian upon admission. In an interview at 1:40 PM on 11/13/14 the [MEDICAL CONDITION] Coordinator (HDC) stated that R#1 had been video taped by the Unit Manager (UM), while walking, with her/his personal cell phone, and the resident was shown the video to demonstrate to her/him how unsteady her/his walking has become. The HDC stated that the resident had said yes when s/he was asked if the Unit Manager and HDC could record her/him to show her/him that her/his walking was unsteady. There was no signed consent from either the resident or the Guardian and according to the HDC, and the Legal Guardian was not contacted regarding the plan to tape the resident while walking to show her/him how her/his walking had declined. The HDC also confirmed that an MD had not been contacted regarding this strategy and that s/he had no professional standard or reference to support this strategy. The HDC stated that the UM had since deleted the video from the cell phone and that s/he had witnessed it. In an interview at 3:40 PM the Administrator and DNS had been informed of the video taping in a morning meeting by other staff and that one of the other nurses had expressed a concern regarding this event. They both stated that the facility was unaware of and did not support this practice. The Administrator confirmed that there was no signed consent for any video … | 2017-11-01 |
| 1350 | 1350 | GREEN MOUNTAIN NURSING AND REHABILITATION | 475040 | 475 ETHAN ALLEN AVENUE | COLCHESTER | VT | 5446 | 2014-08-11 | 164 | D | 1 | 0 | DXGB11 | Based on a confidential family report and staff interview, the facility failed to maintain each resident's right to personal privacy and confidentiality of clinical records for 1 applicable resident (Resident #2). Per a confidential report, a family member reported taking a relative who resides at Green Mountain Nursing Home and Rehab to a medical appointment in July 2014. Upon arrival, s/he discovered that the facility had provided medical information for another resident (Resident #2) to share with the clinic staff instead of that of his/her kin. S/he reported that the medical information included the other resident's first and last name, date of birth, list of medications and a total of 3 pages of health information. Per 8/11/14 interview with a facility UM (Unit Manager), s/he stated that when residents have medical appointments, the facility places a face sheet (includes resident specific identifiers, name and date of birth, next of kin, and insurance information), medication record/current medical orders, and a problem list in an envelope to bring to the appointment. S/he reported uncertainty of how the above mix-up in records had occurred and stated that there was no policy that s/he was aware of regarding sending information to medical appointments. On 8/11/14 at 1:20 PM, the ADNS (Assistant Director of Nursing) confirmed that medical information for Resident #2 was mistakenly given to another resident's family member to bring to a medical appointment; s/he confirmed that the information included a copy of Resident #2's MAR (medication administration record) and problem list (which would include the resident's medical diagnoses). S/he also confirmed that the facility's Resident's Rights and Grievance Procedure states that residents .have the right to have all your medical and personal records kept confidential, except as required by law or regulation. | 2017-08-01 |
| 1387 | 1387 | WOODRIDGE NURSING HOME | 475045 | P.O. BOX 550 | BARRE | VT | 5641 | 2014-07-16 | 164 | D | 1 | 0 | WIRI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to respect and protect 1 applicable resident's right to privacy and confidentiality regarding written communication (Resident #1). Findings include: Per 7/16/14 medical record review, Resident #1 had [DIAGNOSES REDACTED]. The resident had care plans for impaired cognitive function, communication issues and behavioral problems related to dementia with atypical [MEDICAL CONDITION]. A family member was listed as the resident's POA (POA=Power of Attorney: legal document that allows another person the authority to handle financial and personal decisions). On 7/16/14, during a review of a facility self-reported incident, an opened envelope and letter from the Division of Licensing and Protection, specifically addressed to Resident #1, was found in the facility investigation folder. The correspondence, dated 5/23/14, contained the results of an Adult Protective Services (APS) investigation pertaining to Resident #1. On 7/16/14 at 2:34 PM, the facility social services assistant who sorts residents' incoming mail reported that all personal cards and junk mail go to all residents. If a cognitively impaired resident receives bills, they are forwarded to family at their direction. If mail is received from the State of Vermont, s/he reported that (for all residents) s/he gives those letters to a facility social worker who then decides what to do with them; the social worker may (tell the social services assistant) to send the mail to the family or may deliver it to the resident to talk to them about it. S/he reported that there is no written policy for handling mail. S/he reported that for Resident #1, bills are forwarded to his/her relative. S/he reported she does not forward State mail to family but instead lets the social worker handle it as s/he would know the family dynamics better. S/he reported s/he was not able to explain how a State APS letter got into Resident #1's facility folder. Per te… | 2017-07-01 |
| 1454 | 1454 | HELEN PORTER HEALTHCARE & REHAB | 475017 | 30 PORTER DRIVE | MIDDLEBURY | VT | 5753 | 2014-02-12 | 164 | D | 0 | 1 | 751Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure that 5 residents (Residents #190, #191, #1, #6, #2) have the right to personal privacy and confidentiality of his or her personal information and clinical records. The findings include: 1. Per direct observation on 2/10/14 at 3:23 PM on the sub-acute rehabilitation unit, the off going day nurse, along with the the on coming nurse and the on coming licensed nursing assistant, entered room [ROOM NUMBER], a semi-private room. At the time of the observation both Residents (#190 and #191) that resided in the room were present. The nurses and aide approached Resident #191 and proceeded to give bed side report. (Discussion of the resident's diagnosis, rehabilitation status, review of medical history at hospital prior to admission, cognitive level, behaviors exhibited, medications resident takes, assistance level needed by resident by staff and the resident's discharge status.) At the time of bedside report, Resident #190 was sitting approximately 5 feet away from the group only separated by a privacy curtain. The verbal volume of the discussion of the bedside report was loud enough that the surveyor sitting 5 feet away was able to hear all details of Resident #191's bedside report. The same group of staff went to the bed of Resident #190 on the other side of the privacy curtain and proceeded to review this resident's bedside report. At the time of bedside report, Resident #191 was sitting approximately 5 feet away from the group only separated by a privacy curtain. 2. Per observation on 2/11/14 at approximately 3:15 PM, on the sub-acute rehabilitation unit, the off going day nurse, along with the on coming evening nurse and the on coming evening licensed nursing assistant, entered room [ROOM NUMBER], a semi-private room. At the time of the observation both Residents (#6 and #1) that resided in the room were present. The nurses and aide approached Resident #6 and pr… | 2017-05-01 |
| 1463 | 1463 | SAINT ALBANS HEALTHCARE AND REHABILITATION CENTER | 475021 | 596 SHELDON ROAD | SAINT ALBANS | VT | 5478 | 2014-05-28 | 164 | D | 1 | 0 | 2EH311 | Based on administration, staff and resident interviews and facility record and policy review, the facility failed to assure resident's rights for privacy during visitation by immediate family for 1 applicable resident (Resident #1). Findings include: Per 5/28/14 interview at 9:25 AM, Resident #1 stated that s/he has been a resident at St Albans Health and Rehab for 3 years and never had any problems. In March 2014, s/he reported calling his/her family member, I was crying because they (the facility) were evicting me. My (family member) got so mad . (s/he) is protective of me .and thought they were putting me out in the cold. S/he came out and was upset and (s/he) was loud . thought they were abusing me. S/he was yelling but so was the staff. S/he said the four-letter word. Resident #1 added, My family is all I have left I need my (family member) very bad, but they won't allow (him/her) to visit in my room. They are supposed to have a private place for you to visit. The resident expressed that s/he is very upset about the situation, misses seeing his/her family as the visits are very important to him/her. On 5/28/14 at 11:15 AM, the social services director reported that in March 2014, Resident #1 was presented with an eviction notice for nonpayment as the business office was not able to reach the rep payee (responsible financial party). The resident's family came in to arrange payment and was upset that Resident #1 was issued the 30 day notice. Per 5/28/14 interview with the resident and staff and confirmed by the administrator, one family member responded to the above situation with loud verbal behaviors that included foul language and critical remarks related to the facility. On 3/7/14 the facility issued a no trespass notice to Resident #1's family member related to the above incident. On 3/11/14 after a meeting with the resident, family and the ombudsman, the administrator issued a modification of the no trespass notice. The modified notice stated that the facility would allow once a week visitation to take p… | 2017-05-01 |
| 1499 | 1499 | THE VILLA REHAB | 475055 | 7 FOREST HILL DRIVE | ST ALBANS | VT | 5478 | 2014-04-21 | 164 | D | 1 | 0 | 6V1611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to respect and protect 1 applicable resident's right to privacy and confidentiality regarding written communication (Resident #2). Findings include: Per 4/21/14 medical record review, Resident #2 has [DIAGNOSES REDACTED]. His/her 3/26/14 quarterly MDS (Minimum Data Set) documented that the brief interview for mental status was not conducted as the resident is rarely/never understood; there were check marks documenting that the resident had long and short term memory problems; and cognitive skills were listed as severely impaired. The resident has care plans for impaired cognitive function, communication, behavioral problems related to dementia and [MEDICAL CONDITION] and has care plans for mood, paranoia and depression. Per 4/21/14 record review, the resident does not have a guardian but has family that lives nearby; the facility is listed as his/her A/R Guarantor (accounts receivable responsible party). On 4/21/14 at 12:00 noon, the facility's nursing supervisor stated that Resident #2 has a family member that visits him/her on most Saturdays. On 4/21/14 at 12:35 PM, when asked if s/he gets mail, Resident #2 stated, no, s/he thinks all the mail goes to (his/her family). On 4/21/14 at 2:04 PM, the facility business manager stated that the facility does not have a specific policy regarding mail delivery, but generally s/he or the DON (Director of Nursing) sort the incoming mail; resident mail goes to the activity director who brings the mail to the residents and s/he assists them with reading it when requested. If someone has a guardian, all mail goes to the guardian. The facility handles all mail related to representative payee issues. On 4/21/14 at 3:30 PM, the business manager reported that with Resident #2's permission, s/he opened and read a letter addressed to Resident #2 from Adult Protective Services (APS). S/he reported that s/he was unsure what s/he was supposed to do with the… | 2017-04-01 |
| 1558 | 1558 | BERLIN HEALTH & REHAB CTR | 475020 | 98 HOSPITALITY DRIVE | BARRE | VT | 5641 | 2014-04-23 | 164 | D | 0 | 1 | 6UU311 | Based on observation, record review and staff interview the facility failed to ensure that Resident #91 was provided the right to personal privacy and confidentiality of his or her personal and clinical records. The findings include; 1. Per direct observation on 4/22/14 at approximately 8:30 AM, the state surveyor was standing in the hallway on Unit A, approximately 20 feet away from Resident #91 who was sitting in his/her wheelchair in front of the doorway of his/her room in the hallway. At the time of the observation there were approximately 3 other people in the hallway within close proximity to Resident #91. The facility Social Worker (SW) approached Resident #91 in the hallway and was observed asking Resident #91 questions related to feeling depressed, hopeless, trouble sleeping, feeling bad about yourself, and trouble concentrating. The Social Worker recorded the resident's responses on a piece of paper. Per interview with the facility Social Worker on 4/22/14, he/she confirmed in interview that he/she was asking Resident #91 questions in the hallway. The SW indicated when asked if he/she made it a habit to ask personnel questions to the residents in the hallway and he/she indicated it depends on who is around and what is going on. The SW confirmed that the questions he/she were asking Resident #91 were eliciting responses of a personnel and confidential nature and that he/she was asking them in a public area. Per review of the medical record of Resident #91, the medical record indicated that on 4/22/14 at 8:44 AM the facility SW documented a section of the comprehensive assessment for Resident #91, indicating the resident's answers to the assessment questions that the SW asked Resident #91 in the hallway on 4/22/14 at 8:30 AM. | 2017-01-01 |
| 1990 | 1990 | VERNON GREEN NURSING HOME | 475008 | 61 GREENWAY DRIVE | VERNON | VT | 5354 | 2012-05-17 | 164 | D | 1 | 0 | TYUQ11 | Based on record review and staff interview the facility failed to ensure the right to personal privacy and that the contents of two residents medical records were kept confidential for 2 residents identified (Resident #1 and #8), except when release is required by transfer to another healthcare institution; law; third party payment contract; or the resident. The findings include: 1. Per interview with a staff Licensed Nursing Assistant (LNA) on 5/16/12 at 6:05 AM, the LNA stated that another LNA (#1) had taken a picture of Resident #1 and placed the picture from his/her cell phone on the LNA's Facebook account under "favorite residents". Per review of the employee file for LNA #1 on 5/16/12, the file indicated that the LNA was terminated from the facility for posting pictures of Resident #1 on the LNA's personal Facebook account on the computer on 5/7/12 without Resident #1's permission or Resident #1's Durable Power of Attorney (DPOA)'s permission. Per record review Resident #1 was not able to make his/her own decisions and had a DPOA (Durable Power of Attorney) assigned to make all medical decisions regarding care. Per interview with the DNS (Director of Nursing Services) and Administrator on 5/16/12, the DNS and Administrator confirmed that on 5/7/12 a staff LNA was terminated for posting pictures the LNA had taken, of Resident #1's picture from the medical record with his/her cell phone, on the LNA's computer Facebook account. The DNS and Administrator stated that he/she was terminated for violating the rights of Resident #1 and posting his/her picture on a computer Facebook account with out permission from the resident or DPOA. Per interview with the DNS and Administrator on 5/17/12, they confirmed that the posting of a picture of Resident #1 without permission on a computer Facebook account was a violation of the rights of Resident #1. 2. Per interview with a staff Licensed Nursing Assistant (LNA) on 5/16/12 at 6:05 AM, the LNA stated that another LNA had taken picture of Resident #8 and placed the picture … | 2015-08-01 |
| 883 | 883 | ST JOHNSBURY HEALTH & REHAB | 475019 | 1248 HOSPITAL DRIVE | SAINT JOHNSBURY | VT | 5819 | 2016-04-25 | 167 | C | 1 | 0 | V9BD11 | > Based on observation and interview, the facility failed to post the results of the State survey, posted in a place readily accessible to residents and post a notice of their availability. Findings include: Per observation on 04/24/16 at 4:30 PM, the survey results were located in a plastic wall-mounted display folder approximately 58-59 inches off the floor, near the offices. Residents in wheelchairs would not have ready access. In addition, there were other informational documents in the plastic wall-mounted folder. There was no notice of availability posted. The facility Administrator confirmed the above findings, later that evening. | 2019-04-01 |
| 2280 | 2280 | THOMPSON HOUSE NURSING HOME | 475050 | 80 MAPLE STREET | BRATTLEBORO | VT | 5302 | 2011-11-02 | 167 | C | 0 | 1 | 32VQ11 | Based on observation and interview, the facility failed to make the results of the most recent survey available for examination, post in a place readily accessible to residents and post a notice of their availability. Findings include: Per observation on 11/2/11 at 9:36 A.M., the 2010 survey results were located in a plastic wall-mounted display folder behind other informational documents in the entryway between two sets of doors. There was no notice of availability posted. The facility Administrator confirmed the above at the time of the observation. | 2014-10-01 |
| 2302 | 2302 | MAPLE LANE NURSING HOME | 475042 | 60 MAPLE LANE | BARTON | VT | 5822 | 2011-06-29 | 167 | B | 0 | 1 | 33IM11 | Based on observation, resident and staff interviews, the facility failed to post survey results in a place readily accessible to all residents and failed to post a notice of their availability. Findings include: Per resident and staff interviews, 2 residents (#4, 48) out of the total sample as well as 2 staff members (that conduct the monthly resident council meetings) were unaware that they could access the state survey results or where they were posted. Per interview on 6/28/11 at 9:45 A.M. Resident # 48, who was identified by staff as being very active in the resident council and s/he routinely attends all the meetings. When s/he was asked by this surveyor where the state survey results were posted and how s/he could access them s/he stated, 'I'm not sure what that is.' Also, 'No, I have never been told about that, I would like to see a copy of that, where is it located?.' In addition, Resident # 4, who is also very active in the resident council and attends all the meetings stated, 'I know the State comes in once in a while, but I didn't know there were survey results that we could look or where they are.' She also stated, 'My son would like to see them.' Although the survey results were posted on the wall to the left as you enter the building, the survey findings were posted by a thumb-tack on the wall, too high for wheel-chair bound residents to easily access them. Also there was no notice posted of their availability. A review of the Resident Council Meeting minutes for the last year failed to show any discussion of the state inspection survey results, where they are posted or how residents could access them. Per interview with the upstairs Activities Director on 6/29/11 at 10:30 A.M., who is one of the primary staff members that conducts resident council meetings, s/he confirmed that s/he did 'not know where the state inspection results were, that the residents could access them or where they were located.' In addition, on 6/29/11 at 10:56 A.M., per interview with the Social Services Director, s/he confir… | 2014-09-01 |
| 2411 | 2411 | THE MANOR, INC | 475057 | 577 WASHINGTON HIGHWAY | MORRISVILLE | VT | 5661 | 2011-02-09 | 167 | B | YU9Y11 | Based on staff and resident interviews (Residents # 19, 101, 104), the facility failed to ensure that residents were informed that the most recent survey results are available for review by the residents or where the results are posted. Findings Include: Per interview with the Resident Council President on 2/7/11 at 2:00 PM, s/he stated that s/he was 'unaware' that the State Survey & Certification results are posted at the facility or where they are located. In addition, per interviews with Residents #104 & 101 on 2/8/11 between 10 - 10:15 AM, both residents confirmed that they were unaware that they could view the State survey findings or where they were posted. Per interview with the Social Worker (the person assigned to help facilitate Resident Council) on 2/9/11 at 2:15 PM, she confirmed, after reviewing the Resident Council minutes for the past year, that there had been no discussion regarding how the residents could access the survey results or where they are posted. | 2014-04-01 | ||
| 867 | 867 | THOMPSON HOUSE NURSING HOME | 475050 | 80 MAPLE STREET | BRATTLEBORO | VT | 5301 | 2016-06-28 | 168 | C | 0 | 1 | Q85Q11 | Based on observation and staff interview, the facility failed to provide accurate information for contacting advocate agencies (the licensing agency). Findings include: Per observation on 6/27/16 at 5:17 AM of the facility's first and second floor postings of Resident's Rights, the number and address posted for the Division of Licensing and Protection (DLP), was noted to be incorrect. Per interview with the Administrator on 6/27/16 at approximately 9 AM, s/he stated that s/he had recently changed the address and phone number to reflect the current phone number and address of DLP. S/he stated that s/he would make sure the postings were correct following his/her conversation with the surveyors. Per observation on 6/28/16 at 8:25 AM of the first and second floor postings of Resident's Rights, the number and address posted for DLP continued to be incorrect and further confirmation from the administrator that the phone numbers listed on the facility postings were non-working numbers and that a resident would not be able to contact the Division of Licensing and Protection with the current numbers posted. | 2019-05-01 |
| 2369 | 2369 | GILL ODD FELLOWS HOME | 475052 | 8 GILL TERRACE | LUDLOW | VT | 5149 | 2011-02-15 | 170 | B | 1 | 0 | 3MF711 | Based on resident and staff interviews, 8 of 12 applicable residents did not receive their mail in a prompt manner. (Resident #4, #5, #6, #7, # 8,# 9, #10 & #11) Findings include: 1. Per interviews on 02/15/11 from 11:40 AM - 1:15 PM, Residents #4, #5, #6, #7, #8 and #11 stated to the nurse surveyor that they had not received a letter from their physician which was received at the facility on 02/01/11. Residents #9 and #10 stated that their families received the letters instead of them. During the resident interviews, all were determined to be capable of understanding verbal as well as written communication. Per interview at 1:35 PM, the Administrator confirmed that the above residents are their own decision makers and that the letters were not delivered promptly . | 2014-06-01 |
| 1464 | 1464 | SAINT ALBANS HEALTHCARE AND REHABILITATION CENTER | 475021 | 596 SHELDON ROAD | SAINT ALBANS | VT | 5478 | 2014-05-28 | 172 | D | 1 | 0 | 2EH311 | Based on administration, staff and resident interviews and facility record and policy review, the facility failed to assure reasonable access for visitation by immediate family for 1 applicable resident (Resident #1). Findings include: Per 5/28/14 interview at 9:25 AM, Resident #1 stated that s/he has been a resident at St Albans Health and Rehab for 3 years and never had any problems. In March 2014, s/he reported calling his/her family member, I was crying because they (the facility) were evicting me. My (family member) got so mad . (s/he) is protective of me .and thought they were putting me out in the cold. S/he came out and was upset and (s/he) was loud . thought they were abusing me. S/he was yelling but so was the staff. S/he said the four-letter word. Resident #1 added, My family is all I have left I need my (family member) very bad, but they won't allow (him/her) to visit in my room. They are supposed to have a private place for you to visit. The resident expressed that s/he is very upset about the situation, misses seeing his/her family as the visits are very important to him/her. On 5/28/14 at 11:15 AM, the social services director reported that in March 2014, Resident #1 was presented with an eviction notice for nonpayment as the business office was not able to reach the rep payee (responsible financial party). The resident's family came in to arrange payment and was upset that Resident #1 was issued the 30 day notice. Per 5/28/14 interview with the resident and staff and confirmed by the administrator, one family member responded to the above situation with loud verbal behaviors that included foul language and critical remarks related to the facility. On 3/7/14 the facility issued a no trespass notice to Resident #1's family member related to the above incident. On 3/11/14 after a meeting with the resident, family and the ombudsman, the administrator issued a modification of the no trespass notice. The modified notice stated that the facility would allow once a week visitation to take place on Wednesd… | 2017-05-01 |
| 561 | 561 | THOMPSON HOUSE NURSING HOME | 475050 | 80 MAPLE STREET | BRATTLEBORO | VT | 5301 | 2017-05-10 | 176 | D | 0 | 1 | 5XKY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview and staff interview, the facility failed to ensure proper use, storage and documentation of a medication that one applicable resident in the Stage 2 sample has available for self-administration. (Resident #9) Findings include: During resident interview on 5/9/17 at 1:33 PM, Resident #9 stated that s/he doesn't need much help and s/he does everything for him/herself. Observation was made by the surveyor that a bottle of generic cough syrup (cough and chest congestion DM) was on the bedside table. The resident said that s/he has some very bad allergies and that s/he sometimes needs to take some cough medicine and takes it maybe once a month. When asked where s/he keeps the medicine, the resident stated that it isn't hidden and that s/he doesn't keep it locked up. When asked how much s/he takes, the resident responded that s/he doesn't measure it and just takes a swig whenever it is needed. The resident has a [DIAGNOSES REDACTED]. There is a physician order [REDACTED]. Per the Director of Nursing, during an interview at 2:14 PM, the cough medicine referred to is from the standing orders for [MEDICATION NAME] (common name for [MEDICATION NAME]) and not [MEDICATION NAME] DM. The DNS also stated at this time that s/he was not able to find a policy regarding the storage of medications for residents that have been evaluated and deemed safe to self-administer. Per interview with a Registered Nurse (RN) at 2:48 PM confirmation was made that the cough medication was not properly labeled with the resident's name, s/he was unaware that the medication was [MEDICATION NAME] DM, and was not aware of how to store the medication in a resident's room. The RN further confirmed that s/he was unable to determine when or how much the resident takes and that there was no place to document the usage. | 2020-09-01 |
| 868 | 868 | THOMPSON HOUSE NURSING HOME | 475050 | 80 MAPLE STREET | BRATTLEBORO | VT | 5301 | 2016-06-28 | 176 | D | 0 | 1 | Q85Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to assess 1 of 14 residents, (Resident #12), for the ability to self-administer medication. Findings include: Per facility policy titled Medication Administration Self-Administration by Resident dated 10/07 identifies Residents who desire to self administer medications are permitted to do so with a prescriber's order and if the nursing center's interdisciplinary team has determined that the practice would be safe. A self-administration of medication evaluation of the Resident's ability review is to be conducted. The evaluation should be completed for any resident who wishes to self-administer mediations and should be repeated on a regular basis (no less then annually) . Per medical record review, Resident #12, has a physician's orders [REDACTED].#12 may have inhaler at the bedside for personal use. Medication Administration Record [REDACTED]. Per interview with the Registered Nurse (RN)/Charge Nurse, observation of the packaging of the inhaler (packaging is located in the medication cart), identifies that the inhaler has 200 metered doses. There is no documentation identifying on the Medication Administration Record [REDACTED]. The inhaler itself identifies that there are 123 inhalations remaining in the inhaler. Seventy-seven (77) doses have been self administered. The MAR indicated [REDACTED]. RN confirms that the nurses do not check the inhaler at the bedside and are not aware of when the resident self-administers the inhaler. Per interview with the Registered Nurse/Charge Nurse and the MDS (Minimum Data Set) Coordinator, confirmation was obtained that there has not been any evaluations for self-administer of medications for Resident #12, therefore the team has not determined that Resident #12 is safe to self-administer the medication. Facility policy titled Medication Storage/Bedside Medication Storage dated 10/07, identifies that 4b. medications provided to the resident for … | 2019-05-01 |
| 1327 | 1327 | CRESCENT MANOR CARE CTRS | 475033 | 312 CRESCENT BLVD | BENNINGTON | VT | 5201 | 2013-12-04 | 176 | D | 0 | 1 | U2ZU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, facility documentation and staff interviews, the facility failed to ensure that 1 of 5 sampled residents, (Resident #2) was safe for self administration of drugs. The findings include: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per physician orders [REDACTED].@ 10:18 AM identifies, ProAir HFA 90 mcg/actuation aerosol inhaler, inhale 2 puffs by oral route 4 times per day as needed, may keep at the bedside. Per Medication Administration Record [REDACTED]. Per nurses notes dated 8/29/13 identifies a nursing order, medications @ bedside PRN (as needed) signed by an LPN (Licensed Practical Nurse). Per Crescent Manor Care Center Policy and Procedure for Self Administration of Medications, prior to self administration of medications, the residents cognitive, physical and visual ability to carry out this responsibility will be assessed by the interdisciplinary team. There is not evidence in the medical record identifying that an assessment for self-administration of medications was conducted. Per interview with the Unit Manager on 12/3/13 @ 1:40 PM, s/he confirms that there was no assessment conducted prior to obtaining the order for self administration of medication or prior to the resident self administering the inhaler that is kept at the bedside. | 2017-09-01 |
| 1718 | 1718 | KINDRED TRANSITIONAL CARE & REHAB BIRCHWOOD TER | 475003 | 43 STARR FARM RD | BURLINGTON | VT | 5408 | 2013-03-13 | 176 | D | 0 | 1 | QUPM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, staff failed to assure an interdisciplinary team determined a resident was appropriate to self-administer drugs for 1 of 26 residents in the stage 2 sample (Resident #2). Findings include: Per observation of a medication pass on 3/13/13 at 8:35 AM, Resident #2 was given medications by a nurse to self-administer. Per record review on 3/13/13 at 8:55 AM, there was no physician order for [REDACTED]. Per interview with the Unit Manager (UM) on 3/13/13 at 9:03 AM, residents should be assessed for self-administration of medications and a physicians's order is required. The UM confirmed that there is no physician order or nursing assessment for self-administration of medications. | 2016-06-01 |
| 1904 | 1904 | MAPLE LANE NURSING HOME | 475042 | 60 MAPLE LANE | BARTON | VT | 5822 | 2012-07-11 | 176 | B | 0 | 1 | IVIQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure that a Resident who self medicates was assessed for the ability to safely and correctly administer the medications. This affected one (#54) of one Resident identified to self administer medications. Findings include: Per review of the clinical record on 07/10/12, Resident #54 was admitted on [DATE] with [DIAGNOSES REDACTED]. The current list of medications for July 2012 included Deep Sea Nasal Spray 0.65%, two sprays to each nostril three times a day *May keep at the bedside*, and Refresh Tear 0.5% ophthalmic solution, four drops in both eyes three times a day, *May keep at the bedside*. No assessment of Resident #54's physical or cognitive ability to safely or correctly administer eye drops or nasal spray was located in the clinical record. During interview of the Director of Nursing Services (DNS) and the East Unit Manager, Registered Nurse (RN) on 07/10/12 at 4:38 P.M. both verified that Resident #54 kept these medications at the bedside and the Resident administered them. Both stated the physician had ordered this and a plan of care was in place. They denied that staff had observed Resident #54 administer the medication or assessed the Residents physical or cognitive ability to administer the medications as ordered by the physician. During interview of Resident #54 on 07/11/12 at 9:00 A.M., the medications were observed to be on the bedside table. Resident #54 was able to identify the medications and what they were used for. When queried as to how to administer the medications Resident #54 stated I use the nose spray whenever I need it and the eye drops four times a day, with each meal and at bedtime. The Resident could not state how often s/he needed the nose spray or how many drops of each medication were administered each time. During interview of the LPN responsible for Resident #54's medications and the unit manager RN on 07/11/12 at 9:10 A.M. they state… | 2015-11-01 |
| 2035 | 2035 | VERMONT VETERANS' HOME | 475032 | 325 NORTH STREET | BENNINGTON | VT | 5201 | 2012-05-31 | 176 | D | 1 | 0 | YU7B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to determine if one resident (Resident #1) could safely self administer medications prior to arranging for the resident to do so. Findings include: 1. Per record review, Resident #1, whose [DIAGNOSES REDACTED]. Per record review of the facility's investigation of the incident, reported on 5/3/12, written statements by staff RN, Assistant Director of Nursing Services (ADNS), and the Clinical Care Coordinator of Resident #1's unit "discussed the nurse could prepare (h/her) medication and the VCA (Veterans Care Assistant) could hand (Res.#1) a spoon". The statement continues "(Res. #1) would retrieve the medication from the med cup and medicate (h/her self)". Per record review of the facility policy 'Self Administration of Medications', nursing is to use the form "Assessment for Self-Administration of Medications Ability", the Care Plan Team is to review the completed form, the resident is to be evaluated for safety and compliance, and a note on the MAR (Medication Administration Record) to state 'Resident self-medicating.' Per interview with Resident #1 on 5/30/12 at 1:30 P.M. stated s/he had asked Nursing previously if s/he could self-administer medications and "they said 'no'". Per interview with the Administrator (ADM), the Director of Nursing Services (DNS), the Assistant ADM and Assistant DNS on 5/31/12 at 2:30 P.M. confirmed Resident #1 was never assessed for self- administration of medications, and there was no documentation on the MAR indicated [REDACTED]. | 2015-08-01 |
| 2412 | 2412 | THE MANOR, INC | 475057 | 577 WASHINGTON HIGHWAY | MORRISVILLE | VT | 5661 | 2011-02-09 | 176 | B | YU9Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of records, the facility failed to ensure that a resident who self-administered medications was screened appropriately by an interdisciplinary team for 1 applicable resident. (Resident #88) Findings include: 1. Per observation during the afternoon of 02/07/11 and during the day on 02/08/11, the following medications/supplements were on the bedside table of Resident #88: Nature's tears, Fibermucil, Resverstrol 100 mg (milligrams), and Memory & Brain w/ Acetyl L-[MEDICATION NAME] (contains Vitamin A, D, [MEDICATION NAME], and bacopa). A physician's orders [REDACTED]. Per record review on 02/08/11 at 4:30 PM, there was no nursing assessment to determine safe self-administration nor was there a written care plan that addressed the storage of the medication/supplement. Per interview 2/8/11 at 4:15 PM, the DNS (Director of Nursing Services) confirmed there was no assessment or care plan for self administration of medications, nor should the meds be left on the bedside stand. | 2014-04-01 | ||
| 1925 | 1925 | STARR FARM NURSING CENTER | 475030 | 98 STARR FARM RD | BURLINGTON | VT | 5408 | 2012-10-03 | 201 | D | 1 | 0 | IP1011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure that a discharge for one resident (Resident #1) was necessary for the resident's welfare and that the resident's needs could not be met in the facility. Findings include: Per record review, Resident #1 (R#1) was admitted to the facility on [DATE] from home. The resident did have a history of drug-seeking over the counter medications at his/her local pharmacy(s) and of leaving the hospital twice during medical crises. In record review, a Recreation/Leisure Patterns assessment was conducted on 6/15/12, but there is no Activities Care Plan found in the record. Additionally no evidence was found in the Care Plan of development/revisions of specific strategies/activities to reduce exit-seeking behaviors. There are no interventions from the assessment found on the Behavior/Intervention Monthly Flow Records during the time the resident resided in the facility. The record did not provide evidence of interdisciplinary meetings being conducted to reassess the current strategies and to develop resident specific approaches/interventions to try to reduce/prevent exit seeking behaviors. Per staff interview on 10/3/12 at 3:10 PM both the Social Worker and Administrator describe the resident as aggressively seeking to exit the building as soon as one or two days after admission to the facility. In a review of Behavior/Intervention Monthly Flow Records and Nursing notes there are instances of the resident requesting rides from staff to go home or to the store for Tylenol and there are two documented occasions of active intent to elope. The first instance was at 12:30 P.M. on 6/21/12 when the facility received a call from a local cab company that Resident #1 had called at 12:20 P.M. asking for a cab to take her home. At 1:30 PM the same day, the notes state that the resident called 911 and was re-educated regarding the use of 911. There are no other calls to cab companies or 911 noted. T… | 2015-10-01 |
| 1998 | 1998 | MOUNTAIN VIEW CENTER GENESIS HEALTHCARE | 475012 | 9 HAYWOOD AVENUE | RUTLAND | VT | 5701 | 2012-06-13 | 201 | D | 1 | 0 | VJP011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to permit one applicable resident (Resident #1) to remain in the facility and not be transferred or discharged from the facility unless the discharge is necessary for the resident's welfare and the resident's needs cannot be met by the facility. The findings include: 1. Per record review on 6/13/12, Resident #1 was admitted to the facility on [DATE] for short term rehabilitation. Resident #1's [DIAGNOSES REDACTED]. The Nurses Notes (NN) indicate that Resident #1 had a rapid progression in his/her dementia, was unable to remain at home and had numerous hospitalization s. Per review of the facility physicians progress note dated 5/24/12, the physician indicated that Resident #1 had new onset dementia that was progressing rapidly. Resident #1 was noted to be in need of long term living situation because Resident #1 was non compliant with care and medications when at home and that Resident #1's spouse also had significant memory loss and this complicated the care at home. Per Social Service (SS) notes on 5/24/12 at 2:55 PM, Resident #1 was moved to the secure dementia unit and a secure care bracelet was applied related to Resident #1's verbalization of wanting to leave the facility. Per NN dated 5/25/12 at 7:00 PM, Resident #1 became agitated, with an increase in exit seeking behaviors when husband was at facility visiting Resident #1. The NN indicate that on 5/25/12 at 8:50 PM, Resident #1 was exhibiting increased exit seeking behavior, refusing to eat, family was in visiting and needed to be distracted by staff so family could leave the facility. Per NN on 5/26/12 at 9:12 AM, Resident #1 was "asking to leave". The NN indicate that Resident #1 was displaying increased exit seeking behavior, stating that he/she was going to "call the police" and stating "I don't live here." The NN also indicate that Resident #1 was " standing watching exit doors for someone to open them." Per NN, Res… | 2015-08-01 |
| 2093 | 2093 | BERLIN HEALTH & REHAB CTR | 475020 | 98 HOSPITALITY DRIVE | BARRE | VT | 5641 | 2012-02-29 | 201 | G | 1 | 0 | LV9711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview and record review, the facility failed to ensure that a discharge was appropriate because the resident's health improved sufficiently so the resident no longer needed services provided by the facility for one applicable resident. (Resident #1). Findings include: Per record review and confirmed with the Director of Nursing (DNS) on 2/29/12 at 2:03 PM, the 2/3/12 the Admission Nursing Evaluation for Resident #1 states: "Mobility: Ambulates with assist of one, Comments: Ambulates with a walker device and one assist". The 2/21/12 Nursing Discharge Note states, "discharged today home with his son and home health services. Resident did not participate in transfers from bed to wheelchair or wheelchair to car. Very drowsy, non responsive. PT (Physical Therapy) informed." In addition, the DNS confirmed that the MD (physician) was not informed of the resident's condition at time of discharge. Per staff interview with a Licensed Practical Nurse (LPN) on 2/29/12 at 2:45 PM (with the DNS present during the interview), Resident #1 was discharged on [DATE] at 11:00 AM. Prior to exiting the building, s/he stated that Resident #1 was very drowsy. The LPN and LNA (Licensed Nursing Assistant) had to "pick him up to move him from the bed to the wheelchair ". The LPN stated s/he informed the Unit Manager that the resident was very drowsy and not responding to commands. The LPN was directed to proceed with the discharge. The LPN and LNA transported the resident to the car via wheelchair and the resident was unable to assist them in transferring from the wheelchair to the car. The LPN notified the Unit Manager a second time and was told to contact Physical Therapy concerning how they transfer the resident. The LNA picked up the resident and pivoted him/her into the car. The resident's son stated he did not know how he was going to transfer the resident from the car to the house. After returning to the facility, the LPN informed the Unit Manager… | 2015-06-01 |
| 1855 | 1855 | ROWAN COURT HEALTH & REHAB | 475037 | 378 PROSPECT STREET | BARRE | VT | 5641 | 2013-01-30 | 202 | D | 1 | 0 | WY2L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that there was specific documentation within the medical record for 1 of 10 residents identified (Resident #1) by the residents physician of the necessity for the discharge, what was tried prior to the discharge to prevent the need for discharge and why the facility can no longer meet the specific needs of the resident being transferred. The findings include: 1. Per review of the medical record on 1/23/13, Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the progress notes by the Unit Manager, he/she indicated that Resident # 1 was discharged from the facility on 8/5/12 related to Resident #1 frightening staff and residents. Per documentation in the medical record on 8/5/12 at 2:56 PM, the Registered nurse indicated that Resident #1 was transferred to ER for severe agitation, combativeness, disrobing and refusal to be controlled. Per review of the physician's orders, a verbal order was obtained from a physician at 6:00 PM to transport to CVMC ER. Per review of the clinical record, there was no evidence in the physicians progress notes indicating the specific need for Resident #1 to be discharged to the emergency room , there was no evidence in the clinical record by the physician of what interventions were utilized to assist Resident #1 with his/her behaviors and how and why interventions were not successful and how the facility was unable to meet the needs of Resident #1 at the facility. Per review of the facility policy titled Physician Services, the policy indicates that Physicians orders and progress notes shall be maintained in accordance with current OMBRA regulations and facility policy. Per review of the clinical record by the Interim Director of Nursing (IDNS) on 1/30/13, he/she confirmed that there was no documentation by the facility physician in the clinical record of Resident #1 regarding the specific need for Res… | 2016-01-01 |
| 2437 | 2437 | ROWAN COURT HEALTH & REHAB | 475037 | 378 PROSPECT STREET | BARRE | VT | 5641 | 2010-11-02 | 202 | D | 58FI11 | Based on staff interview and record review, the facility failed to provide written documentation by the resident's physician of the reasons for transfer or discharge for one of three resident's in the applicable sample. (Resident #1) Findings include: 1. Per staff interview and record review, there is no documentation by the physician in the clinical record of Resident #1 stating the reasons for transfer or discharge to another facility. Per interview with the Assistant Director of Nursing (ADON) and record review on 11/2/10 at 1:30 PM, Resident #1 was transferred and then discharged from the facility on 1/31/10 in order to be evaluated and treated at another health care facility. While the Nurse's Notes on 1/31/10 indicate that there was a change in the resident's condition, there is no documentation by the resident's physician of the reasons for the transfer or discharge. This was confirmed with the ADON in interview on 11/2/10 at 1:30 PM. | 2014-03-01 | ||
| 425 | 425 | GREEN MOUNTAIN NURSING AND REHABILITATION | 475040 | 475 ETHAN ALLEN AVENUE | COLCHESTER | VT | 5446 | 2017-06-20 | 203 | E | 1 | 0 | 9M6T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge and the reasons for the move for 7 applicable residents in the sample (Residents #3, 4, 5, 6, 7, 8 and 9). 1. Per interview and record review, Residents #3, 4, 5, 6, 7, 8 and 9 were emergently discharged on [DATE] due to the facility's contracted therapy company ending their services on 6/2/17. Due to a lack of Physical, Occupational and Speech Therapies, these residents were discharged to other locations to continue their skilled therapies. Per interview with the Social Service staff member on 6/19/17 at 2:05 PM, no written discharge/transfer notices that contain the required information and appeal rights were provided to the residents, nor their legal representatives at the time of transfer. Per resident interview at 1:05 PM on 6/20/17, Resident #9 was discharged to another nursing facility without advance notice on 6/6/17 and stated s/he did not know why. Per interview with the Administrator on 6/14/17 at 11 AM, she stated that the facility was under the impression that there would not be a break in service when the former therapy company ended their services, but found out during the day on Monday, 6/5/17 that there would be a lapse in therapy services, and they proceeded with discharges on 6/6/17. | 2020-09-01 |
| 529 | 529 | WOODRIDGE NURSING HOME | 475045 | P.O. BOX 550 | BARRE | VT | 5641 | 2017-09-12 | 203 | D | 1 | 0 | KINI11 | > Based on staff interviews and record review the facility failed to notify the resident and/or the resident's representative in writing of hospital transfers and a discharge from the facility for one applicable resident (Resident #1). Findings include: Per record review, Resident #1 was having violent, psychotic behaviors and was transferred to the hospital Emergency Department (ED) on 7/17/17 at approximately 7:45 PM. The resident was sent back to the facility at approximately 11:00 PM with a hospital sitter. On 7/18/17 at approximately 12:50 PM the resident was sent back to the hospital ED for an evaluation and a possible admission. There was no evidence in the medical record that the resident and/or resident's representative was notified in writing of the transfer on either 7/17/17 or 7/18/17. Per record review, on 7/18/17 the resident was sent back to the ED; labs and urine cultures were unremarkable, and his/her head scan was normal so s/he was medically cleared. The case was further discussed with psychiatry and the resident was cleared for discharge back to the facility; and at this time the facility refused to accept the resident. The ED Physician and Nursing Supervisor were made aware that a meeting had taken place with an upper level hospital administrative team and an agreement was made to admit the resident to the hospital. Upon further record review, the administrator documented on 7/26/17 at 11:06 AM, They (the hospital) are actively looking for placement in another facility as they are aware that the resident poses a safety risk to the resident who was the focus of the resident last Monday. I did offer to assist with placement as the facility feels a sense of responsibility as the resident has lived at the facility for quite some time now. On 7/28/17 at 9:20 AM the administrator wrote, We (the daughter) had a conversation on the phone, during this time, I again expressed regret on behalf of the facility that we would be unable to take her family member back due to safety concerns for the other res… | 2020-09-01 |
| 732 | 732 | ST JOHNSBURY HEALTH & REHAB | 475019 | 1248 HOSPITAL DRIVE | SAINT JOHNSBURY | VT | 5819 | 2016-10-11 | 203 | D | 1 | 0 | F5E611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, resident representative and staff interviews, the facility failed to ensure that the regulatory requirements for notification after an emergent discharge of a resident were met for one resident sampled (Resident #1). Findings include: Per record review, Resident #1 had lived at the facility for two years. Although the resident had some behavior concerns, there was no record of the resident having violent outbursts, and staff had been successful in redirecting the resident's behaviors without serious incident. There was an incident on 7/17/16 at the facility where the resident became paranoid and agitated, and proceeded to destroy property, break a window, and was acting in a threatening manner. The police and the ambulance service were called and came to the facility. The resident was transported to the Emergency Department by family members who were able to calm the resident first. The resident's spouse was told after the emergent discharge that the resident would be allowed to return to the facility after the hospital stabilized the resident's condition. The spouse came to the facility on [DATE] and signed a 10 day bed-hold notice, and was told that they were moving Resident #1 to a private room upon return, and that they would allow the resident to return. On 7/23/16, the resident's spouse was told that due to the behavior of Resident #1, they would not be allowed to return to the facility. Per interview on 10/11/16 at 1:15 PM, the Medical Director who is also the primary physician for this resident stated that he was advocating for the resident to return to the facility after adjusting medications at the hospital, however the Corporate representatives denied the readmission due to safety concerns. The regulatory requirements for an involuntary emergency discharge were not met for the following: The legal representative for the resident (spouse) was not issued a discharge notice that included the reason for the di… | 2019-10-01 |
| 917 | 917 | PINES REHAB & HEALTH CTR | 475044 | 601 RED VILLAGE ROAD | LYNDONVILLE | VT | 5851 | 2016-03-23 | 203 | D | 1 | 0 | V5CF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that a resident received written notification of discharge with the required information provided to them for one resident sampled (Resident #1). Findings include: Per record review on 3/23/16, Resident #1 was admitted to the facility on [DATE] after a hospital admission. [DIAGNOSES REDACTED]. There were safety concerns regarding this resident during their stay at the facility, including being caught twice smoking marijuana inside their room creating a fire hazard, as well as outdoor infringements of the facility's smoking policy. Per the Administrator, they were about to issue an involuntary discharge to the resident due to the serious safety concerns and the resident disregarding the rules of the facility. Before the Administrator issued an involuntary discharge notice to the resident, they were hosptalized on [DATE]. Later on that same day, the resident's spouse came to the facility to pick up the rest of the resident's belongings, and stated that Resident #1 was not going to return to the facility, and they were looking for options closer to their home. The Administrator did not issue an involuntary discharge notice after hearing this, as Resident #1 was considered discharged per their own choice. The Administrator stated that about two weeks later, a Social Services staff person from the hospital called to say that Resident #1 wished to return to the nursing home. The Administrator refused to readmit the resident, citing the safety concerns as the reason. Per interview on 3/23/16 at 3:45 PM, the Administrator confirmed that the resident wished to return to the facility, however this was denied, and done so without issuing an involuntary discharge notice with all the required appeal rights and information included. | 2019-03-01 |
| 1492 | 1492 | VERMONT VETERANS' HOME | 475032 | 325 NORTH STREET | BENNINGTON | VT | 5201 | 2014-04-01 | 203 | D | 1 | 0 | Q9LY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview and record review, the facility failed to ensure 1 of 3 residents (Resident #1) of the sample group was given the required 30 days notice prior to discharge from the facility. Findings include: Per record review of Physician order [REDACTED]. Per record review and confirmed during interview with the facility's Administrator (ADM) on 4/1/14, the first discharge notice for Resident #1 is dated 2/10/14. The notice was deemed not to include all the information required by state and federal regulations, and was redrafted and dated 3/3/14. The 3/3/14 notice states we intend to discharge you from this facility on Feb. 10, 2014. Per interview with the ADM and the Social Worker on 4/1/14 at 10:47 A.M. there is no documentation that Resident #1 received the required notice of discharge 30 days before h/her discharge order was written. | 2017-04-01 |
| 1607 | 1607 | SAINT ALBANS HEALTHCARE AND REHABILITATION CENTER | 475021 | 596 SHELDON ROAD | SAINT ALBANS | VT | 5478 | 2013-12-30 | 203 | D | 1 | 0 | H5RX11 | Based on administrative interview and medical record and policy review, the facility failed to provide the resident and/or a family member or legal representative of the resident, with notice of discharge in writing and in a language and manner they understand, which includes the effective date of discharge, the location to which the resident is discharged , a statement that the resident has the right to appeal the action to the State and contact information for the State long term care ombudsman for 1 of 3 residents in the survey sample. (Resident #1) Findings include: Per record and handout review and interview on 12/30/13 at 1:09 PM, the facility administrator confirmed that the facility did not provide written notification of discharge from the facility as soon as practicable to Resident #1 and/or his/her legal representative after s/he was transferred to the hospital and subsequently discharged from the facility. Per record review, Resident #1 experienced a significant change in his/her medical condition on 10/18/13 which necessitated hospitalization . Per review, the facility's Information and Rights for Patients and Residents handout, states on page 18-19 (under the heading, Discharge and Transfer Information), Except under certain circumstances, we will not transfer/discharge you without first giving you thirty (30) days written notice. The notice, which will be in a language and manner understandable to you and, if known, to your Representative or family member, will set forth the reasons for the transfer/discharge, the effective date of the transfer/discharge and the location to which you will be transferred/discharged . In addition, the notice will advise you of your rights to appeal the Center's action, and will provide you with the appropriate names, addresses, and telephone numbers of the State Long Term Care Ombudsman . Per regulation, the notice may be made as soon as practicable before transfer or discharge as the resident required an urgent hospitalization and had not resided in the facility for… | 2016-12-01 |
| 1916 | 1916 | ST JOHNSBURY HEALTH & REHAB | 475019 | 1248 HOSPITAL DRIVE | SAINT JOHNSBURY | VT | 5819 | 2012-10-09 | 203 | D | 1 | 0 | JO3L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to provide written notice to Resident #1, or the legal representative, at least 30 days prior to transfer or discharge. Findings include: 1. Per record review, Resident #1 was transferred to the hospital on [DATE] when his/her pain exceeded that which could be controlled by medication. At that time, the facility issued a notice that Resident #1 would not be readmitted to the facility because of inability to meet his/her acute care needs. Per review of written records of 8/8/12, the State Agency had determined that this situation did not meet the requirements of an involuntary discharge, and that Section 3.12 of State of Vermont Licensing and Operating Rules for Nursing Homes requires a Nursing Home to allow a resident to return to the facility, if among other items, the facility can meet the resident's needs. The letter continued to say that once the facility secured sufficient psychiatric services to be able to meet the resident's needs, the expectation of the regulations is that the resident be accepted back provided he/she continues to desire to return. Hospital records show that Resident #1 was medically stabilized, evaluated by a psychiatrist, and deemed ready for discharge (with treatment recommendations) to the nursing home on 7/31/12. Hospital records showed that Resident #1 did prefer to return to the facility. Review of the medical and psychiatric records showed that the care needs of Resident #1, though certainly challenging, did not exceed the capacity of nursing home care. During an interview on 10/9/12 at 3:30 PM, the Administrator confirmed that Resident #1 was not readmitted to the facility, and that no notice of intent to discharge (with current reason for denial and right to appeal) was issued at that time. | 2015-10-01 |
| 1926 | 1926 | STARR FARM NURSING CENTER | 475030 | 98 STARR FARM RD | BURLINGTON | VT | 5408 | 2012-10-03 | 203 | D | 1 | 0 | IP1011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure that the legal representative for Resident #1 was notified in writing of the discharge and reasons for the move. In addition, the written notice was required to include the effective date of transfer or discharge; the location to which the resident is transferred or discharged ; a statement that the resident has the right to appeal the action to the State; the name, address and telephone number of the State long term care ombudsman, as well as the appeal rights. Findings include: Per record review Resident #1 was admitted to the facility on [DATE]. On 6/7/12 the Resident's daughter was notified that the Resident was asking staff for a ride to a pharmacy to obtain Tylenol and was considered an elopement risk. On 6/8/12 a Social Work note states that the Resident's daughter wishes the Resident to remain in the facility for long-term care (LTC). It also states that the Guardian was informed that the Resident might be more appropriate for a locked/secure unit and would likely do well at assisted living since (Resident) is fairly independent with ADL's (Activities of Daily Living). Dtr understands that (this facility) may not be appropriate for LTC. On 6/26/12 a Social Work note states that there was a prolonged conversation with the Daughter/ Guardian regarding exit seeking behaviors and a request for permission to seek a local secure/locked unit was obtained. The note stated Will continue to work with family on more appropriate placement. In interview, the Administrator and Social Worker stated that though they had spoken with the Daughter/ Guardian they had never stated that the resident was being discharged and that they believed that the daughter was in agreement with the discharge until 7/2/12 when she (Daughter/guardian) stated that the Resident would not be leaving Starr Farm or going to Rutland. Both the Administrator and SW confirmed that the Legal Guardian was not… | 2015-10-01 |
| 1999 | 1999 | MOUNTAIN VIEW CENTER GENESIS HEALTHCARE | 475012 | 9 HAYWOOD AVENUE | RUTLAND | VT | 5701 | 2012-06-13 | 203 | D | 1 | 0 | VJP011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to provide written notice of involuntary discharge of one resident (Resident #1) from the facility and failed to ensure that the resident understood their right to appeal the action to the State. The findings include: 1. Per record review on 6/13/12, Resident #1 was admitted to the facility on [DATE] for short term rehabilitation. Resident #1's [DIAGNOSES REDACTED]. The Nurses Notes (NN) indicate that Resident #1 had a rapid progression in his/her dementia and was unable to remain at home and had numerous hospitalization s. Per the NN dated 5/26/12 at 6:14 PM, Resident #1 continues on 15 minute monitoring, Resident #1 agitated, exiting seeking pacing the halls and Resident #1 was in dining room looking out the window. Staff reported 10 minutes later Resident #1 could not be found. Administrator and police were notified. Resident #1 was returned to facility by local police. Resident #1's secure care bracelet was found on the ground, outside Resident #1's bedroom window. Resident #1 was evaluated by the Nurse Practitioner (NP) on 5/26/12 and no injuries were found. Resident #1 stated that he/she would leave again if he/she needed to. On 5/26/12 Resident #1's family met with the NP and staff nurse and were informed by the NP that the facility Administrator had indicated that the family needed to take resident home that the Administrator had indicated that the facility could not meet the needs of Resident #1. Per NN medications were reviewed with the family and Resident #1 and family left the facility that same evening. Per review of the medical record there was no evidence that Resident #1 or Resident #1's family received any education or paperwork regarding why Resident #1 was being discharged from the facility and Resident #1's rights regarding challenging the discharge decision. Per interview with on 6/13/12 at 11:15 AM with the facility Administrator, Director of Nursing Services… | 2015-08-01 |
| 2438 | 2438 | ROWAN COURT HEALTH & REHAB | 475037 | 378 PROSPECT STREET | BARRE | VT | 5641 | 2010-11-02 | 203 | D | 58FI11 | Based on staff interview and record review, the facility failed to provide the resident, and a family member or legal representative of the resident, with notice of discharge in writing and in a language and manner they understand, which includes the effective date of discharge, the location to which the resident is discharged , a statement that the resident has the right to appeal the action to the State, and contact information for the State long term care ombudsman for 2 residents in the applicable sample. (Resident #1, Resident #2) Findings include: 1. Based on staff interview and record review, the facility did not provide written notification of discharge from the facility to Resident #1 and Resident #2, or their legal representatives, as soon as practicable after they were transferred and discharged to an outside health care facility. Per record review both residents experienced a change in their condition which necessitated evaluation and treatment at an outside health care facility. Per interview with the Assistant Director of Nursing (ADON) and the Admission Director on 11/2/10 at 1:48 PM, the facility did not give written notification of discharge to these two residents, even though the facility's own Admission Agreement document, which is given to all residents prior to their admission, states on page 5, under 11 d. "Transfer or Discharge by the Center: The Patient will receive written notification of the Center's plan to discharge or transfer the Patient and the reasons such a discharge or transfer is necessary, in accordance with the requirements of state and federal law." | 2014-03-01 | ||
| 1574 | 1574 | STARR FARM NURSING CENTER | 475030 | 98 STARR FARM RD | BURLINGTON | VT | 5408 | 2014-01-22 | 204 | D | 1 | 0 | IVLL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and administrative and staff interviews, the facility failed to assure a safe and orderly discharge for 1 of 3 sampled residents (Resident #1). Findings include: Per record review on 1/22/14, Resident #1 was admitted to the facility on [DATE] for long term care. S/he had [DIAGNOSES REDACTED]. Per review of his/her 3/1/13 MDS (Minimum Data Set) quarterly review, s/he required extensive assistance for transfers and personal care and used a wheelchair. Per medical record review, Resident #1 had falls on 4/30, 5/2, 5/6 and 5/8/13. His/her care plan at the time of discharge on 5/15/15 listed the resident as high risk for falls related to confusion, poor communication, gait and balance problems and diminished safety awareness. Per 1/22/14 interview at 10:39 AM, the Director of Social Services reported that on 5/15/13, a(NAME)Farm maintenance worker transported Resident #1 to skilled nursing facility B (SNF-B) for transfer. Per 1/22/14 interview at 1:06 PM, the driver confirmed transporting Resident #1 to SNF-B but could not specifically identify who s/he notified that the resident had arrived or who accepted responsibility for the resident. Per 1/22/14 interview at 3:48 PM, the Director of Nursing Services (DNS) reported that s/he was contacted by the DNS from the receiving facility after the transfer and was told that Resident #1 had been dropped off and had fallen; the DNS at the receiving facility reported they did not know that Resident #1 was in the lobby (at the time of the fall). On 1/22/14 at 1:52 PM, the(NAME)Farm DNS reported that s/he did not document the conversation with the receiving facility's DNS or write up the event as an incident as once Resident #1 had been transported to the receiving facility, s/he was no longer our patient. Per 1/22/14 review of the facility's Discharge/Transfer of the Patient policy provided by the DNS, there is no specific procedure for transportation of residents during transfers or … | 2017-01-01 |
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CREATE TABLE [cms_VT] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );