cms_VT: 29
Data source: Big Local News · About: big-local-datasette
rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
29 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2018-04-03 | 689 | G | 1 | 0 | ZOGT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, direct observation, staff and resident interviews between 4/2-3/2018, the facility failed to ensure that the environment was free of accident hazards for 1 of 7 residents (Resident # 1). The specifics are detailed below: Per medical record review on 4/2/2018, Resident # 1 suffered second [MEDICAL CONDITION] 01/31/2018 on his/ her abdomen, chest and upper left thigh after spilling a cup of coffee. Wounds on the abdomen and chest healed quickly. Wound assessments of the left thigh by both the physician and nursing staff resulted in daily dressing protocols being changed 3 different times, before the area healed on 4/3/2018. Resident # 1 is observed in bed on 4/2/2018 with a dressing in place over the left thigh, denying any pain or discomfort. Resident # 1 is able to articulate that it happened from coffee. Resident # 1 requires assistance and supervision with meals and eats all meals in the main dining room. Unit staff confirm during interview on 4/2 and 4/3/2018 that Resident # 1 was having breakfast in the dining room on 1/31/2018 when the injury occurred. Interview with the food service director on 4/3/2018 in the late afternoon confirms that liquid temps were not being taken before the coffee urn was taken to the unit dining room, but that after being notified that an incident happened, the coffee temperatures were checked and ranged between 170 and 190 degrees. As a result of this incident, temperatures of hot liquids are now taken prior to serving the residents. The food service director further states that Resident #1's meal ticket indicates that a cup with lid is to be used for liquids. This is confirmed by unit staff and on the care plan. The cup with the lid is a sturdy, hard plastic cup with a secure lid and large handle for residents to hold. Protocols were put in place after the injury that include taking temperatures of hot liquids, providing covered cups to residents to minimize injuries if cups are dropped and directions to not leave residents unsupervised who are at risk for spilling liquids/food. There have been no further injuries of this nature throughout the facility since (MONTH) (YEAR). This tag is cited as past non-compliance. | 2020-09-01 |