cms_VT: 54
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
54 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2018-10-24 | 656 | E | 1 | 1 | 73OO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interview, the facility failed to develop a written comprehensive care plan for 5 of 27 residents in the applicable sample (Residents #4, 18, 62, 72, 101). Findings include: 1. Per observation during initial tour of the unit on the morning of 10/22/18, the room of Resident #101 is posted with a sign asking visitors to check with a nurse, and a cart containing personal protective equipment is stationed near the door. During record review and staff interview, it is confirmed that Resident #101 has an infectious disease [DIAGNOSES REDACTED]. The written comprehensive care plan for Resident #101 does not contain specific strategies to direct staff in providing care with infectious disease precautions. On 10/23/18 at 4:03 PM, the Director of Nursing confirmed that no care plan section was developed for infectious disease precautions for Resident #101. 2. Per record review for Resident # 62, staff failed to include daily weights in the care plan. There is a physician order [REDACTED]. Per review of the weight log in the electronic medical record (EMR), there were 13 missed weights between 9/29/18 - 10/22/18. Additionally, the order for daily weights is not reflected in the resident's plan of care. This was confirmed by the Unit Manager on 10/23/18 at 1:47 P.M. 3. Per record review and observation during survey, Resident #4 is in a wheelchair and totally dependent on staff for activities of daily living. According to the medical record, the resident developed a pressure ulcer on their heel on 6/17/18. Although treatment was initiated and continued until it healed, a plan of care was never developed to reflect the actual skin breakdown. Per interview on 10/24/18 at 11:59 AM, the Unit Manager confirmed that there was a care plan for Skin Integrity risk, however that there was not a care plan developed for actual skin breakdown after the resident developed a pressure ulcer. 4. Per record review, Resident #72 had a care plan in place for being at high risk of skin breakdown with interventions in place. The resident developed a Stage 2 pressure ulcer on the coccyx on 9/21/18. The care plan did not reflect the development of the pressure ulcer. Per interview on 10/24/18 at 11:15 [NAME]M., the Unit Manager confirmed that the care plan had not been revised to indicate that Resident #72 had developed a pressure ulcer. 5. Per record review, Resident #18 is on precautions for [MEDICAL CONDITIONS] and the personal protective equipment for staff is noted at the door of the room. There is no care plan present in the record for precautions and/or [MEDICAL CONDITION]. The facility Director of Nursing Services (DNS) confirmed on the afternoon of 10/23/18 that there was no care plan available for Infection Control/ Precautions available for this resident. | 2020-09-01 |