cms_VT: 32
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 32 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2019-05-01 | 622 | J | 1 | 0 | IOQ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff and resident interview, the facility failed to permit 1 of 4 residents sampled (Resident #1) to remain in the facility, and not transfer or discharge. Findings include: Per record review and staff interviews on 4/29-30/19, the facility alleged that there was a resident initiated AMA (against medical advice) discharge on 4/24/19. This was confirmed by the administrator and Director of Nursing (DNS) on 4/30/19 at 9:00 AM, based on the signature of Resident #1 on an AMA document, signed at 1:00 PM on 4/24/19, and verbal expression of desire to leave the facility during an Interdisciplinary Team (IDT) meeting just prior (per Social Services notes of 4/24/19 and interview on 4/29/19 at 12:30 PM). On 4/29/19 at 2:15 PM, the Recreation Assistant, who was present at the IDT meeting of 4/24/19, stated that Resident #1 had described that s/he simply wanted to go downtown that day. 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. Based on the behavior of Resident #1, returning to the facility twice on the afternoon of 4/24/19 and verbalizing that s/he made a mistake, this could also be viewed as a therapeutic leave on the part of the resident, and an unsafe decision related to potential cognitive changes caused by brewing bacterial urinary tract infection [MEDICAL CONDITIONS]. The unit manager witnessed Resident #1 in the building at approximately 3:30 PM on 4/24/19 on 4th floor unit, per interview on 4/29/19 at 12:05 PM. The Administrator and DNS stated on 4/30/19 at 9 AM, that on 4/24/19 around 3:30-4 PM they brought Resident #1 into the conference room and allowed phone use to call the daughter and others. It was stated that a staff person had to dial the phone related to hand tremors of Resident #1. Per review of the comprehensive care plan regarding discharge planning, it is clear that a discharge to the community was not the plan. Per Occupational Therapy assessment dated [DATE], the resident required supervision outside of the building and per interview on 4/29/19 at 12:45 PM, the OT stated that the resident had poor judgement and safety awareness. The health status was declining at the time of discharge 4/24/19 (diagnosed [DATE] as septic with UTI, requiring hospital admission and intravenous antibiotics). In hospital documents of 4/25/19, Resident #1 reported having been at the hotel for 3 days, when in fact it had been approximately 24 hours from entry to the hotel 4/24/19 6:30 PM, per statement of maintenance person who did the transport in facility van, 4/29/19 at 11:25 AM. This statement of 3 days in the hotel represents evidence of lost orientation to time. Both the maintenance person, who called 911 from the hotel, and the DNS, mentioned that on 4/24/19 Resident #1 needed assistance to dial the phone related to hand tremors. 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]. An additional factor is that Resident #1 had a recent history of going off the premises on 4/19/19, per record review and confirmed by the administrator, DNS, and social worker during interviews on 4/29/19. The facility called the police and sent a staff person to bring Resident #1 back to the facility, and re-entry was permitted on 4/19/19. Resident #1 had been in discussions regarding autonomy and choices from January, 2019 through 4/24/19, and disagreed with restrictions the facility put in place regarding independence. There is no written evidence that the facility notified the ombudsman or issued a 30 day notice of discharge during the period prior to the 4/24/19 alleged AMA discharge. Per interview with the Long Term Care ombudsman on 5/1/19 at 8:40 AM, the facility had never contacted him/her about this resident's issues surrounding independence or desire to leave the facility AMA until 4/25/19, the day after discharge. | 2020-09-01 |