cms_VT: 31
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 31 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2019-05-01 | 600 | J | 1 | 0 | IOQ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and resident interview, the facility failed to provide goods and services to the resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress for 1 of 4 residents sampled (Resident #1). Findings include: Per medical record review 4/29-5/1/19, Resident #1 is paraplegic (paralyzed in the lower body) due to a (YEAR) trauma, with other [DIAGNOSES REDACTED]. S/he was assessed and care planned to require staff assistance of 1-2 for bed mobility, transfers from bed to chair, personal hygiene, and catheter care. S/he could eat a regular diet with provision and setup by staff. Leading up to an unsafe discharge on 4/24/19, Resident #1 had known psychosocial and mental health needs that were not addressed by the facility. The facility failed to ensure that the resident received appropriate treatment and services to address his/her alcohol dependence, risk of isolation, feelings of loss of freedom and independence, and coping with an overall decline in health and function, as stated in the written plan of care and diagnoses. The resident, age 64, was rendered paraplegic by trauma and was admitted to the facility 6/27/18. Record review shows no evidence that the resident was referred for professional mental health assessment and/or professional, medically-related social services to address these issues of trauma, loss, addiction, and adjustment, from admission through discharge on 4/24/19. During interview on 4/29/19 at 12:30 PM, the social worker described only having routine care conferences and doing some research to find placement closer to family. On 4/30/19 at 9:00 AM, the Director of Nursing and Administrator related difficulty finding an alternate placement closer to home. Per interview with the Nurse Practitioner (NP), 4/30/19 at 9:35 AM, s/he confirmed that s/he was unaware of any psychological referral. Record review showed that at least 3 facilities had refused admission. The nearest family lives 2 hours away. During the above interviews, the Administrator, DNS, and NP referred to Resident #1 as non-compliant with various aspects of care and services. From admission through 1/22/19, Resident #1 was allowed 1 beer per day, and had a medical order for this. Due to an incident on 1/21/19 where staff observed Resident #1 allegedly having more than 1 beer with 2 other people, the medical order for 1 beer per day was discontinued. There was no evidence that Resident #1 received referral or treatment for [REDACTED]. Resident #1 did show a change in behaviors from that time until 4/24/19. This included an elopement (leaving the building without signing out) on 4/19/19 to assert his/her right to leave the premises. When Resident #1 again left the premises on 4/24/19, an AMA (against medical advice) process was initiated by the facility. Facility staff, not the resident, initiated the discussion about discharge AMA when the resident was adamant about wanting to socialize independently outside the facility that day. There is no facility policy that requires residents to sign out AMA when they wish to go on a therapeutic leave. The facility thought the resident was leaving the building to go to a friend's to live, but took no steps to ensure care/services at that discharge location, nor confirm that as an option. The facility discharged the resident and ordered a maintenence staff person to transport him/her to a local hotel, paying for a one-night stay, on 4/24/19. The facility knew at that time that the family did not intend to care for him/her that evening. The facility knew that the resident could not get from wheelchair to bed, had difficulty dialing a phone, and needed help with catheter care, stool incontinence, all personal hygiene, and could not acquire food, drink, medications or future housing without assistance. The resident was known to have a history of serious UTI [MEDICAL CONDITION], and a current deep tissue pressure sore on the buttocks which could become infected without regular hygiene and care. The facility did not notify the family until some time on 4/25/19 of the hotel location. The facility did not do a Visiting Nurse Association referral by fax until midday, 4/25/19, per copy of fax transmission. This was confirmed by the Administrator and Director of Nursing (DNS) on 4/30/19 at 9:00 AM. Significant harm and risk of death resulted from this discharge, per review of hospital documents. Per interview of 2 maintenance staff, on 4/29/19 at 11:25 AM, Resident #1 was moved into a hotel room with belongings and medications, and 911 was called from the hotel room at approximately 6:30 PM on 4/24/19. The maintenance person who did the transport was not a caregiver and noted that s/he needed to dial the phone for the resident because Resident #1 gets shaky when tries to zero in with hands. Per hospital records, dated 4/25/19, Resident #1 reported to the physician that his/her hand tremors increased previously as a heralding (warning symptom) to UTI. Resident #1 had a history of [REDACTED]. Per interview of Resident #1 on 4/29/19 at about 3:30 PM, the rescue squad summoned by the maintenance person transferred the resident to bed, removed a soiled brief, and emptied the catheter bag, which had leaked on the resident's clothing. On 4/25/19, at approximately noon, an anonymous concerned facility staff person, per interview on 4/29/19, called the resident at the hotel. The resident did not know how to use the phone to reach hotel staff, so the staff person called the police and asked for a welfare check. It was later on 4/25/19 that hotel staff called 911 and ambulance response transported the resident to University of Vermont Medical Center (UVMMC) at approximately 6:12 PM, arriving 6: 34 PM, per dispatch records. Per review of hospital records of 4/25/19, upon emergency department assessment, Resident #1 was not oriented to time, saying s/he had been at the hotel for three days vs the actual 24 hours. The exam revealed the following: Mildly tremulous, unstageable ulcer of coccyx, covered in feces, arrives unable to care for self at motel, ruptured foley (catheter) bag, leukocytosis (high white blood cell count) and fever (100.5 F), abnormal urine dipstick with urine brown and cloudy. Given 1 gram Tylenol for reported headache, and hydrated with intravenous (IV) bolus 1 Liter [MEDICATION NAME] ringers. Attending (physician) attests to failure to thrive after sudden discharge from rehab, associated AKI (acute kidney infection) in addition to leukocytosis and fever, with UA (urinalysis) consistent with complicated UTI (urinary tract infection). Attending notes that patient reports similar heralding of increased hand tremors with previous UTI. admitted to hospitable for further UTI care and placement/housing. Per observation of Resident #1 by this surveyor, on 4/29/19 at 3:30 PM at UVMMC, the resident was receiving IV (Intra-venous) treatment for [REDACTED]. The resident therefore is confirmed to have declined to a level of serious harm and potentially life-threatening status of septic UTI during the 24 hour hotel stay, subsequent to sudden discharge by the facility, with no care rendered after 1:00 PM on 4/24/19, despite the resident returning to the facility twice during the afternoon of 4/24/19 clearly in need of care/assistance and indicating to the DNS that s/he made a mistake. The facility did not make any attempt to contact the resident at the hotel or secure caregivers except to fax a VNA referral at 1:30 PM on 4/25/19, with no check of follow through by the VN[NAME] Per interview on 4/30/19 at 9:00 AM, the Administrator and DNS confirmed that the resident was considered discharged after the AMA was signed, 1:00 PM on 4/24/19, and that they had arranged the transport and paid for a one night hotel stay. See also F0561, F0622, F0626, F0656, F0660, F0742 and F0745. | 2020-09-01 |