cms_VT: 69
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 69 | BURLINGTON HEALTH & REHAB | 475014 | 300 PEARL STREET | BURLINGTON | VT | 5401 | 2017-12-14 | 725 | F | 0 | 1 | 0QUX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to assure sufficient nursing staff to provide consistent nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. Findings include: 1). During interview at the Resident Council meeting on 12/12/17 at 10:06 A M., the seven active residents that were present, strongly voiced there are issues around staffing and they all had to wait a period of time to receive help. They expressed that although they like the staff, there isn't enough of them and they're doing their best but sometimes it is just hard to wait. The Residents stated that there was no one specific shift or day of week, rather it depended on what unit needed help and then that shorts the other floors. One anonymous resident stated that, at one point, she wasn't turned for three hours and staff does not respond in a reasonable amount of time usually around meal times and in the middle of the night. 2). Based upon direct observation and confirmed through interviews staff did not provided the needed care and services for Resident #144 who needed dining assistance. On 12/12/17 at 12:12 P.M., Resident #144 was observed in the dining area at a far table, slightly bent forward, out of reach of the table, with the soup bowl and drinks both having covered lids. Although four facility (non-nursing) employees were in the dining area helping set up tables and serving the plates, none offered to cue and help feed this resident. The nursing staff (LNAs), who were helping other residents with meals and answering call lights, assisted this resident at 12:48 P.M. Resident #144 waited greater than half hour while other residents including the table mate, were served, ate and left the dining room. ALSO SEE F-677. 3). Per interviews with interviewable residents, who wish to be anonymous, on one unit, three of six residents stated that waits for assistance when the call lights are used are long. One resident stated that during meals and at change of shifts waits are 1/2 hour or more. Another resident stated that despite the fact that s/he should have assistance, there have been times when the wait was so long that s/he has gone to the bathroom without the required assistance. 4). In a requested interview with a family member of a resident, who wishes to be anonymous, staffing affects care. The family member, interviewed on 12/12/17, stated that the resident requires the assistance of two staff to safely ambulate. The resident should be ambulated 1-2 times a day and there have been days that this has not been done because staff was too busy or there weren't two people available. As a result the family member states that the resident's ability to ambulate has not improved and may have declined. Additionally when the resident was moved from a rehabilitation unit to a long term care unit the resident experienced new episodes of incontinence due to the lack of staff assistance. 5). In a review of the call light log response times are as follows: During the period of 12/7 10 am to 12/10/2017 9:34 pm there are 256 times when call light response times for units 3, 4 & 5 are longer than 10 minutes with some waits greater than 1 hour. During the period of 12/11 2:34 am to 12/14/2017 9:54 am the response times spread among units 3, 4, & 5 are as follows: 10-15 minutes- 184; 16-21 minutes- 53; 22-26 minutes- 34; 27-32 minutes- 14; 33 minutes and above- 15; The longest waits break down as follows: Unit 3: 34 minutes x2 35 min 38 min 40 min Unit 4: 43 min Unit 5: 33 min 35 min 38 min 46 min x2 47 min 48 min 49 min. 6). Per review of Resident #45's medical record, it identifies that the resident is at end stage Kidney Disease and has been receiving Hospice services. The resident is at risk for falls. In the month of (MONTH) (YEAR), falls have occurred on 12/1/17 and 12/11/17. The Interdisciplinary Care Plan identifies that Resident #45 is to be in a supervised area when out of bed. Per observation on 12/13/17 at 1:05 PM, Resident #45 was in the TV lounge, in a recliner and was sitting upright with both legs elevated. No staff presence identified. At 1:07 PM an Licensed Nurse Aide (LNA) enters the lounge and removes lunch trays. At 1:15 PM an LNA walks through the area. At 1:30 PM, the Registered Nurse (RN) staff educator enters the lounge and sits with Resident #45. Fluids that have been sitting on the table in front of the resident, are offered. The RN provides the resident with a blanket and leaves the area. At 1:33 PM, the resident is sound asleep in the TV lounge unattended. At 1:40 PM the RN directs staff to assist the resident to bed. Per interview with the RN at 1:40 PM, confirmation was made. that the Resident #45, has been left unattended in the TV Lounge. S/He also confirms that care plan does identify that the resident is to be attended when out of bed. | 2020-09-01 |