cms_VT: 37
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 37 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2019-05-01 | 657 | D | 1 | 0 | IOQ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon record review and interview, the facility failed to assure the plan of care was revised to reflect the care and services provided to one of two residents (Resident #2). Findings include: 1. Per record review, Resident #2's care plan completed by the Social Worker (SW) dated 4/8/19, did not accurately reflect the resident's mental status. The care plan states Resident #2 has impaired/decline in cognitive function or impaired thought processes related to a condition other than [MEDICAL CONDITION]. The interventions include monitor conditions that may contribute to cognitive loss/dementia, including metabolic causes, respiratory problems, [MEDICAL CONDITION], delusions, hallucinations, psychiatric disorder, poor nutrition, hearing or vision impairment, new/acute heath problem, head injury, pain fever, dehydration or alcohol withdrawal. Evaluate needs for psych/behavioral health consult. Per record review of the Brief Interview for Mental Status (BIMS), which was completed upon admission by the SW states Resident # 2 has a score of 15. BIMS is used to obtain a snapshot of how well a person is functioning at the moment. A score of 13-15 is cognitively intact. Per staff interview, SW confirmed on 4/30/19 at 8:15 AM that the care plan for Resident #2 was inaccurate as written on 4/8/19 and the resident was mentally alert and cognitively intact. SW did not revise the care plan prior to the resident's discharge on 4/25/19. SW stated the computer generated care plan auto populates and staff completing the care plan need to make adjustments as needed. Stated she/he should have revised the care plan from has cognitive impairment to has the potential for cognitive impairment. 2. Per record review, Nursing note dated 4/11/19 states, Noted two 1 centimeter by 1 centimeter to patient mid-spine after patient complained of soreness. Noted redness with mild drainage. Applied 3 by 3 inch [MEDICATION NAME] dressing. Per staff interview and confirmed with with the Unit Manager on 4/29/19 at 12:57 PM, Resident #2's care plan for Has actual skin breakdown dated 3/25/19 related to surgery was not revised to include skin breakdown noted on 4/11/19 to mid [MEDICATION NAME] spine in 2 areas. 3. Per record review, Resident #2's care plan dated 3/25/19 states resident requires assistance/is dependent for Activities in Daily Living (ADL) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion. Interventions include extensive assist of 2 for transfers using a walker. Per staff interview and confirmed with Unit Manager on 4/29/19 1:08 PM, Resident # 2 was admitted post surgery and was dependent for assistance in bathing, grooming personal hygiene, dressing, eating, bed mobility transfers, locomotion, toileting and extensive assistance with transfer, and the care plan was not revised to include the 4/8/19 the care conference review which indicated the Resident #2 was upper body moderate assist, lower body maximum assist, transfers moderate assist. Ambulation minimum assist with Contact Guard Assist (CGA). | 2020-09-01 |