08-24-?i5 @218 St Joseph Home Burl 8028845840 $830 PRINTED: FORM APPROVED Division of Licensing and Protegtion STATEMENT oF osFICIchiss do) MULTIPLE constnucnon no) DATE sunst AND PLAN OF CORRECTION A BUILDING COMPLETED - - - 0155 a csizsizcis NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 243 NORTH PROSPECT STREET BURLINGTON, VT 0540'] {xii} In I SUMMARY STATEMENT OF ID PROVIDERS PLAN or CORRECTION - (st PREFIX DEFICIENCY MUST BE Pascao?o BY FULL pagan: (EACH CORRECTIVE ACTION SHOULD as counters TAG REGULATORY on Lee IDENTIFYING TAG CROSS REFERENCED To THE APPROPRIATE DATE DEFICIENCY) ST RESIDENTIAL GARE HOME Initial Comments? . An unannounced on?site survey was conducted by the Division of Licensing and Protection on 8/26/15 as a follow up to the survey of.7/6/15 in which regulatory violations were identi?ed. A complaint investigation was conducted in conjunction with the follow up survey There were .no roguiatory violations identified related to the complaint The following regulatory violation resulted from the follow up surVey. v. RESIDENT cans AND HOME SERVICES {size} i 5.5 General Care 5.5a Upon a resident?s admission to a residential care home, necessary services shall be provided or arranged to meet the resident?s perSonal, nursing and medical care needs; This REQUIREMENT is not met as evidenced by: Based on staff intei?view?end record review the home failed to provide supervision of '1 of2 applicable residents in a manner to assure the resident's identified safety needs were met. (Resident#1). Findings include: Per record review staff failed to adequately monitor the location of Resident which led to hisfher subsequent elopement and absence from the home for a period of approximately 3 hours and 40 minutes without staff knowledge The resident's most recent assessment dated 3/5/15 identified him/her with moderate impairment in his/her cognitive ability for daily decision making. Division of Licensing and Protection msomroav DIRECTORS on Pnovms RISUPPLIER SIGNATURE TITLE co) DATE Kc: oft - Q?i AK i4 manic 1QCH12 . inof-g STATE FORM 08-243 5 12:20 St Joseph Home Burl 8028845840 T-880 F-048 - PRINTED: cannabis . FORM APPROVED Division of Licensing and Protection, STATEMENT on DEFICIENCIES on) PsoVIoERrsueruEwcuA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF NUMBER: A BUILD COMPLETED . ENG. R?c .. 0155 B. WING 0312612015 NAME 0F PROVIDER OR SUPPLIER STREET ADDRESS. STATE. ZIP CODE . - 243 NORTH PROSPECT STREET ST JOSEPH 5 RESIDENTIAL CARE HOME BURLINGTON, VT 0540?! (X4) Io STATEMENT or DEFICIENCIES .ip PLAN os CORRECTION (x5) PREFIX DEFICIENCY MUST BE PRECEDED av FULL pREpix CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY on Lee EDENTIFYING TAG csoss-REFERENch To THE APPROPRIATE oArE . l? {8126} Continued From page 1 A Care Plan Conference was held on mans and indicated the resident was at risk; ?Because {sine} loves to walk [sihe] is at risk of walking off the premises and getting lost?. The racerd revealed the resident had a history of wandering as evidenced by hisiher disappearance on 5/21/15 when Slhe had gone for a walk and was returned to the home approximately 2 hours later by police after staff had been unable to locate him!her. Despite this identified rislt a subsequent progress note indicated that on the night of 8116115 at 11:50 PM local police had contacted the home to notify staff they had found the resident wandering a distance from the home. The note further I indicated that staff had no idea the resident had i eidped Or how long s/he had been missing from i the home. i During interview the DNS (Director of Nursing Services) stated that rounds are concocted by both an off-going and an tin-coming caregiver, together, at the change of every shift to determine presence of each of the residents. HoWever, although both the caregivers had documented the presence of Resident #1 during the 11:00 PM shift change rounds on snails, both caregivers later acknowledged they had not physically seen the resident at that time. In additiOn, despite the fact that a caregiver had documented that resident rounds, had been conducted eyery two hours during the 8118(15 evening shift, in with the home?s policy, the DNS and the Administrator both acknowledged that per review of a video recording 'itwas determined that Resident #1 had exited the facility without staff Knowledge at approximately 8:10 PM and was not returned until approximately 3 hours and 40 minutes later, indicating a failure, by staff to adequately supervise/monitor the resident. has the locator device. placement. Resident 1. As of 8/30/15 Resident 1 has 1:1 private duty from 4:00pm-8:00pm 7 days a week. When the private duty care givers are not here we do hourly checks. To ensure that hourly checks are being completed, Med Tech verifies with caregiver hourly and both sign the assigmnent sheet (see attached) attesting that the checks and other tasks Were completed. Tthe hourly verifications will be ongoing until Resident 1 has found other We are actively seeking nursing home placement and have requested a legal guardian to help Resident 1 make decisions. We also are looking into the VNA adult day program as an option for - As of BIQOI 15, we have changed the activation time of our door alarm system from 9:00 pm to 8:00pm. We have also had our alarm system vendor, increase the system testing from weekly to daily. - As of 8/20f15 we have contracted With Care Trek Northeast, to use a GPS tracking system to locate Resident 1 should he slope. The Burlington Police Department ~Both employees were given a corrective action plan for not checking resident at change of shift and documenting that it was complete and he was - Pot/moved, slide- Division of Licensing and Protection STATE FORM 190H12 :1?ch item If continuation sheet 2 of 3 08- 24-515 12:20 FROM- Division Of Licensing and PrOteOtiD'n Joseph Home BUTI 8028845840 $880 F-048 FHIN I LIL): FORM APPROVED is a repeat deficiency* I I I I STATEMENT OF (X1) (sz MULTIPLE CONSTRUCTION x3 DATE SURVEY AND PLAN OF CORRECTION. IDENTIFICATION NUMBER: A BUILDING, 0155 8- WING .DBIZEIZMS NAME OF PROVIDER DR SUPPLIER STREET ADDRESS. GITYI OTATE. ZIP - - 243 NORTH PROSPECT STREET ST JOSEPH 5 RESIDENTIAL CARE HOME BURLINGTON, VT 05.401 . (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION {st DEFICIENCY MUST BE PRECEDED RY FULL p?gnx CORRECTIVE ACTION SHOULD BE DOMPLETE TAG . REGULATORY OR ESQ IDENTIFYING INFORMATION) TAG THE APPROPRIATE DATE . DEFICJENCY) From page 2 {8123} #:er I5 (.LIMUIVIIECTT dark 6% 900/ Palmn?i IIW ?Ii, Im?xm G'jc In 7/34, . Division Of Licensing and Protection FORM 68 53 1QCH12 continuation sheet 3 of 3