cms_VT: 47
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 47 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2019-06-26 | 842 | D | 1 | 0 | NSOU11 | > Based on record review and interviews the facility failed to assure that the medical record for Resident #4 were complete and accurately documented. Findings include: Per record review Resident #4 is very limited in speech due to cognition, and has a BIMS (a cognition assessment tool) of 3 indicating severe cognitive impairment. According to documentation the resident's speech was limited to 1-2 word statements. According to a written statement on 6/6/19 by the LNA, on 5/28/19 at approximately 5 am, the resident complained of pain when a Licensed Nursing Assistant (LNA) lifted the Right Arm to assist in dressing. The LNA immediately stopped moving the arm and went to report the complaint of pain to the 11 pm-7am nurse (the Licensed Pratical Nurse (LPN) on duty) as it was not usual for that resident. The LPN's written statement indicates that on 5/28/19 the resident was evaluated and when asked about the presence of pain would simply say my butt. The statement dated 6/4/19 indicates there was no bruising or discoloration in the Right shoulder/ arm. There was no grimacing or report of pain when the arm was touched' according to the statement. An LNA statement by a Day Shift LNA states that on 5/28/19 s/he went to get Resident #4 out of bed. When the LNA was trying to put the resident's shirt on the resident complained of pain. The LNA stopped and immediately went to get the LPN assigned to that resident's corridor on the day shift. The day LPN wrote in a statement that at 7-7:30 am on 5/28/19 that the LNA had come to have the nurse check Resident #4. Upon checking the resident the LPN found that the resident's R shoulder was lower than the other shoulder. It was also swollen and cold to the touch. The resident repeated hurt and my arm. The note also said, 'Spoke to the night nurse. No report of pain. Notified the NP {Nurse Practitioner} and RN {Registered Nurse} Both in to assess. The resident was sent to the ER (emergency room ) at 8 am. The written statement by the RN on Day shift states that the LPN called her to assess the resident. The resident showed non-verbal signs of pain. The APRN (Advance Practice Registered Nurse) saw the resident, ice applied, the MD (Medical Doctor) notified. In a review of the medical record for Resident#4 on 6/24-26/19 there are no progress notes by the facility LPN's or the facility RN regarding the events of the early morning hours of 5/28/19 when Resident # 4 complained of pain and was transferred to the ER. Upon transfer to the ER for evaluation the resident was found to have a fracture of her Right Humerus (long bone in the upper arm). In an interview on 6/24/19 at 9:30 am the LPN from the day shift stated that there had been nothing during morning report that indicated there had been an issue with Resident#4. S/he stated that when the LNA reported at 7 am the complaint of pain when Resident #4 was being assisted s/he asked the 11 pm-7 am LPN if there was anything different during the night for Resident #4 and s/he responded no there wasn't. The day LPN also stated that s/he had not documented anything regarding the incidents described for Resident #4 on 5/28/19. On 6/25/19 at 8 am, via telephone interview the RN on the Day shift confirmed that s/he had not documented her assessment of the resident or any other information in the resident record for the incident on 5/28/19. In an interview on 6/26/19 at 7:05 am the 11 pm-7 am LPN stated that her description of the events in her statement were accurate but she did not find any issues so she didn't write a progress note or mention what happened in report. In an interview on 6/26/19 at 10:45 am the Director of Nurses (DNS) confirmed that it is expected that nursing staff would have documented that events regarding the event on 5/28/19 for Resident #4. | 2020-09-01 |