A VERMONT . AGENCY OF HUMAN SERVICES DEPARTMENT OF DISABILITIES, AGING AND INDEPENDENT LIVING Division of Licensing and Protection 103 South Main Street Waterbury, VT 05671-2306 Voice/TTY (802) 871?3317 To Report Adult Abuse: (800) 564-1612 Fax (802) 871-3318 April 16, 2015 Ms. Mary Belanger, Administrator St Joseph's Residential Care Home 243 North Prospect Street Burlington, VT 05401-1609 Dear Ms. Belanger: Enclosed is a copy of your acceptable plans of correction for the survey conducted on March 23, 2015. Please post this document in a prominent place in your facility. We may follow-up to verify that substantial compliance has been achieved and maintained. If we find that your facility has failed to achieve or maintain substantial compliance, remedies may be imposed. Sincerely, Pamela M. Cota, RN Licensing Chief Developmental Disabilities Services Adult Services Blind and Visually Impaired Licensing and Protection Vocational Rehabilitation uu?h?lhul?I?U ilPl .I eutu PRINTED: 04I'03i?2015 FORM APPROVED Division of Licensinq and Protection STATEMENT OF (x1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 03i23i2015 0155 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS. CITY. ZIP CODE 243 NORTH PROSPECT STREET ST USE ESIDEN CARE HOME BURUNGTON. VT 05401 0141") 5 SUMMARY STATEMENT OF II) PROVIDERS PLAN OF CORRECTION . utsi PREFEX '5 . MUST BE PRECEUED BY FULL PREFIX . (EACH CORRECTIVE ACTION SHOULD BE 5 COMPLETE TAG REGULATORY on LSC TAG To THE APPROPRIATE DATE i i DEFICIENCY) . Rico: lnitiai Comments: 5 R100 An unannounced onsite complaint investigation was conducted by the Division of Licensing and 1 Protection on 3(23115. The following reguiatory . findings were identi?ed. Two of the regulatory ?1 vioietions were determined to required immediate i corrective action due to the immediate jeopardy T: I they posed to the health and safety of the I residents of the home. The home submitted immediate corrective action plan to this i on March 27: 2015, which was acceptedR126 V. RESIDENT CARE AND HOME SERVICES SSr?i R126 5.5 General Care 2 5.5.3 Upon a resident's admission to a 1 residential care home, necessary sewices shall i a be provided or arranged to meet the resident?s i i i i i personal, nursing and medicai care . ineeds. This REQUIREMENT is not met as evidenced by: Based on record review and staff interview. the . home failed to ensure that necessary services i were provided to meet the resident's needs for a one sampied resident (Residentiil?i). Findings 1 i I inciUde: Per record review on 323115, Resident #1 had i resided at the home since admission on 812912. The resident had diagnoses that included dementia and depression. Some or the behaviors i . documented for this resident included a ression, and wandering behaviors with an i .. idgegntified elopement risk. For review of tine i . a? Division of Licensing and Protection LABORATORY 0R REPRESENTATIVES (I5) DATE STATE FORM . 5389 02m? ifoontinualion sheet to?! Addenduml Phi? phone will With \H'iS'iiS': ?the (Mom nurse, will tor ensiuivxj ?the News Ewe 'tuxnul in ?*er The Difei??m U8 Nursing "is tov Nata R303 acceoifd wiWi Hli's?ll'i' Division of Licensing and Protection IOK LUICI iuwoam ruub/U'li PRINTED: 04f03r?201 5 FORM APPROVED HUI STATEMENT or: oencnences (in Peovioerusu {x2} MULTIPLE CONSTRUCTION (x3; DATE SURVEY- AND PLAN OF CORRECTION NUMBER: a BUILDING COMPLETED 0155 8? 03I2312015 NAME OF Pnovloen on SUPPLIER STREET ADDRESS, CITY, STATE. cope . 243 NORTH PROSPECT STREET ST JOSEPH 5 RESIDENTIAL CAR HOME . BURLINGTON, VT 05401 (X43 SUMMARY OF DEFICIENCIES lo PLAN OF CORRECTION (st PREFIX (EACH DEFICIENCY MUST BE PRECEDEO BY FULL I PREFIX CORRECTIVE SHOULD BE 5 TAG REGULATORY on Lee IDENTIFYING TAG To THE APPROPRIATE . WE i DEFICIENCY) I R125, Continued From page 1 i R126 . I 1 called upon to come in and visit with the resident nurse's notes, the resident was often up at night, needing attention from staff, and family was often to settle their anxiety. Per review Of the notes, an 3 incident occurred on 10i23i14 at 4:30 AM where . the resident was found in the stairway without a their car. . Per review of the nurse's note from 2/26/15. walker, down one flight of stairs, was very confused, and told staff that s/he was looking for Resident#i was found by the LNA on duty at i 5 1:46 AM sitting outside of the building, outside thel 5 dining room deor, confused, in a tee shirt and i underwear, and without a walker. The LPN on duty with the LNA wrote that the resident had abrasions on lower left leg, hands, and sacrum, as well as signs Of frostbite on toes and fingers. The temperature outside was well below zero degrees according to weather data and the transported to the Emergency Room, and admitted to the hospital with signi?cant frostbite - approximately 10 days, the resident was admitted and hypothermia. After the hospital stay of i i i . resident?s family member. The resident was i I I to a skilled nursing facility and passed away. i Per review of Resident#i's medical record, the plan of care identi?ed himfher as an elopement risk and a wanderer. Problems listed on the plan of care included: History of attempts to leave Interventions included Toileting every 2 hours and facility unattended, Resident wanders aimlessly, Impaired safety awareness, Disoriented to place at times places resident at risk of getting to a potentially dangerous place/stairsioutside of i i i facitity, and attempts to descend back stairs. i I - as needed during the day and evening, at 11?12 i AM, between 5 and 6 AM to prevent wandering to i ?nd bathroom. Staff statements indicated that he i Division of Licensing and Protection STATE FORM 6593 Plan of Correction: 1. As of 3/26/15, we have alarmed i all exit doors with alarms that can be heard throughout the building. These alarms will be activated at 9:00 pm every evening by the evening Med Tech. They will remain on until 5:00 am when the Night shift Med Tech tic-activates. 2. Staff has been instructed on the use of these alarms and has received a written policy regarding the use of the alarms. Please see attached policy. 3. We are conducting rounds more frequently on the evening and night shifts paying particular attention to the 2 residents that are at risk of clopement. As of March'26, 2015, the above corrections are in place. if continuation sheet 2 or Division of Licensing and Protection rax nor 3 2015 10:38am 04l03l201 5 FORM AP PROVED was Checked on around 12 midnight during rounds. and was in histher room at that time- observed that a doorbell system had been i . .. During a tour of the home at10;25 AM, it was installed on the dining room door where Resident #1 had exited on 2t26i15. The front door of the home also had a previously existing doorbell system. Per observation of the other 3 doors on the ground ?oor near the dining room. there were i no alarms installed on any of those exits. There are also no doorbells on these doors to allow someone to alert staff that they were locked out. . There was also an area near the dining room that i had double unlocked doors with a sign indicating that it was an employee only area. however easily entered potentially by a resident if they ignored the sign, and leading to an unlocked door off the laundry room. Per interview 0n 303/15 at 10:45 AM, the Head of Maintenance stated that three alarms had been purchased forihe home, which if activated would make aloud sound if someone i opened the door. The Head of Maintenance management to install them. as there was a concern abdut disturbing residents with a loud 5 alarm at night if someone exited. i i stated that s/he was waiting for approval from I I Per interview on mans at 11:15 PM with the 3 Manager of the home, there had been discussions around how to make the building more seCure from possibie resident eiopements, however no ?nal decision had been made as to what type of system should be installed at the for Vermont Catholic Charities stated that home. Per interview at that time also, the Controller and Director of Professional Services although discussions were had by administratiOn about a soiution to the ee?urity of residents. there had been no ?nal decision as to what system ivieton of Licensing and Protection STATE FORM tie ?oszn STATEMENT OF (X1) PROWDERISUPPLIEFUCUA {x2} MULTIPLE (x3) DATE SURVEY AND PLAN OF coRReoTlON NUMBER: A COMPLETED 0155 0312312015 NAME OF PROVIDER on suppose STREET ADDRESS, otTY, STATE. ZIP CODE 243 NORTH PROSPECT STREET ST CARE OME BURLINGTON, VT 05401 txq} to SUMMARY STATEMENT OF lo 5 Pow oF CORRECTION i 1X5) PREFIX (EACH DEFICIENCY MUST BE PRECEBEU BY FULL .- PREFIX (encH ACTlon 3E comma-re me REGULATORY on LSC TAG CROSS-R EFEREN ceo TD THE APPROPRIATE 5 DATE 5 - R126 Continued From page 2 R123 If continuatlon sheet 3 of I?ux HDF .5 auto ?tuzdtlam PRINTED: 04(031?201 5 . . FORM APPROVED of Licensing and Protection STATEMENT OF DEFICIENCIES (X1) MULTIPLE CONSTRUCTION (X3 a SURVEY AND PIAN OF NUMBER: A. BUILDWG: COMPLETED 3 0155 - 03(2312015 NAME OF PROVIDER SUPPLIER ST RESIDENTIAL CARE HOME STREET ADDRESS. CITY, STATE. ZIP CODE 243 NORTH PROSPECT STREET BURLINGTON. VT 05401 not) PREHX TAG SUMMARY STATEMENT OF (EACH UEFICIENCYMUST BE PRECEOEU av FULL REGULATORY on IN FORMATION) EU PREFIX TAG PROVIDER PLAN OF CORRECTION i (x51 (EACH CORRECTIVE ACTION SHOULD BE CROSS REFERENCED To THE APPROPRIATE DATE 8126 R286 Continued From page 3 would be installed to better secure the home. Per interview on 3t23t15 at 9:55 AM, the Director of Nursing Services identified two current I residents with dementia who were considered at risk for atonement. One of them resided in a - room on the ground floor that was close by and easily accessible to an exit that had no aiert system on it to indicate someone had exitedthe awake staff working the overnight shift. and they completed rounds of the building less than an hour before Resident #1 exited the door on the night of2t26l15, and found the resident in their room at that time The DNS also confirmed that although the staff are awake and checking on i R126 i door. The DNS stated that there were always two I i 1 residents the possibility still existed for a resident I to exit undetected by staff if they were in another i part ofthe building at the time. lX, PHYSICAL PLANT 9ft Environment 9.1.3 The home must provide and maintain a - safe. functional sanitaryi homeliKe and comfortable environment. This REQUIREMENT is not met as evidenced by: Based on record review and staff interview. the home failed to provide and maintain a safe environment for one sampled resident (Resident Findings include: . Per record review on 3f23l15? Residentiit had resided at the home since admission on 8l29f12. The resident had diagnoses that included Division of Licensing and Protection STATE FORM R266 .. -.. emu? GEM Plan of Carrection: 1. As of 3/26! 15, we have alarmed all exit doors with alarms that can be heard throughout the building. These alarms will be activated at 9:00 pm every evening by the evening Med Tech. They will remain on until 5:00 am when the Night shift Med Tech dcactivates. 2, Staff has been instructed on the use of these alarms and has received a written policy regarding the use of the alanns. Please see attached policy. 3. We are conducting rounds more frequently on the evening and night shifts paying particular attention to the 2 residents that are at risk of elopemcnt. As of March 26, 2015, the above corrections are in place. I 02KW11 It continua'Jan sheet 4 off} Division of Licensing and Protection IVA (?ii?II .J LUIZJ tuaddaiu 041035.015 FORM PROVED dementia and depression. Some of the behaviors 5 documented for this resident included aggression. and wandering behaviors with an . identified elopement rislc. Per review of the nurse's notes, the residentwas often up at night, needing attention from staff, and family was often I called open to come in and visitwith the resident - to settle their anxiety. Per review of the notes. an incident occurred on 10/23i?l4 at 4:30 AM where . the resident was found in the stairway without a walker, down one flight of stairs was very confused and told staff that s/he was looking for their car. Per review of the nurse's note from 2/26i15: Residentit?l was found by the LNA on duty at . 1:45 AM sitting outside of the building, outside the; dining room door, confused in a tee shirt and underwear, and without a walker. The LPN on duty with the LNA wrote that the resident had abrasions on lower left leg? hands, and sacrum, as well as signs of frostbite on toes and ?ngers. The temperature outside was well below zero degrees according to weather data and the i resident's family member. The resident was transported to the Emergency Room, and admitted to the hospital with signi?cant frostbite and hypothermia. After the hospital stay of approximately 10 days, the resident was admitted - to a skilled nursing facility and passed away. Per review of Resident #1?s medical record. the plan of care identified him/her as an elepement 5 risk and a wanderer. Problems listed on the plan of care included: History of attempts to leave facility unattended. Resident wanders aimiesmy, impaired safety awareness, Disoriented to place at times places resident at risk of getting to a potentially dangerous placefstairsioutside of facility. and attempts to descend back stairsDivision of Licensing and Protection STATE FORM 02KW11 STATEMENT OF {Xi} PROWDEFUSUPPLIERICLIA (x2) (X3) DATE SURVEY AND paw OF CORRECTION NUMBER: A BUILDING COMPLETED 0155 3- WING NAME 0? 0R SUPPLIER STREET ADDRESS. CITY, STATE. ZIP cooe 243 NORTH PROSPECT STREET . ST CA HOME BURLINGTON, 05401 poi} Io SUMMARY STATEMENT OF lo 1 PLAN OF CORRECTION 9(5) DEFICIENCY MUST BE Pascsoso BY FULL Fees-?ix CORRECTIVEACTION SHOULD BE 3 COMPLETE TAG REGULATORY OR TAG . CROSS-REFERENCEU To THE . DATE . R266 Continued From page 4 i R266 . if continuatictn Sheet 5 of 6 Division of Licensing and Protection ld? a lUidtla??l 04f03i?201 5 FORM APPROVED STATEMENT OF AND PLAN OF PROVIDERISUPPLIERICLIA MULTIPLE CONSTRUCTION (X3) DATE SURVEY NUMBER: A BUILDING COMPLETED 0155 5- 031231201 5 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE 243 NORTH PROSPECT STREET ST CARE HOME VT 05401 not} 10 SUMMARY STATEMENT OF in PLAN or: no; paeszx (EACH DEFICIENCY MU ST BE PRECEOED BY FULL PREFIX CORRECTIVE ACTION BE census-re TAG REGULATORY as Leo IDENTIFYING R266 Continued From page 5 Interventions included Toileting every 2 hours and 3 . as needed during the day and evening. at 11?12 I AM, between 5 and 6 AM to preventwanderlng to - find bathroom. Staff statements indicated that he was checked on around 12 midnight during rounds, and was in hislher room at that time. During a tour of the home at 10:25 AM. it was observed that a doorbell system had been installed an the dining room door where Resident #1 had exited on 212mb. The front door of the . home also had a previously existing doorbell system. Per observation of the other 3 doors on 9 the ground floor near the dining room, there were no alarms installed on any of those exits. There are also no doorbells on these doOrs to allow someone to alert staff that they were looked out. There was also an area near the dining room that 9 had double unlocked doors with a sign indicating that it was an employee only area, however easily entered potentially by a resident ?rl they ignored the Sign. and leading to an unlocked door off the laundry room. Per interview on 303/15 at 10:45 AM, the Head of Maintenance stated that three ialerms had been purchased forthe home. which i if activated would make a laud sound if someone opened the door. ?The Head of Maintenance stated that slhe was waiting for approval from management to install them, as there was a concern about disturbing residents with a loud alarm at night if someone exited. Per interview on 3l23l15 at 11:15 PM with the Manager of the home, there had been discussions around how to make the building more secure from possible resident elopements. however no final decision had been made as to what type of system should be installed at the home. Per interview at that time also, the Controller and Director of Professional Services . . - . 1 TAG T0 THEAPPRO PRIATE GATE . R266 DEFICIENCY) Division of Lic'?nsing and Protection STATE FORM 93W ozlmm It continuation sheet 6 01?5 Division of Licensing and Protection Ian oucdulmuo rim a euro l?UlU/Ull PRINTED: 0410312015 FORM APPROVED AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 0155 B. WING STATEMENT OF (X2) MULTIPLE CONSTRUCTION no} DATE sum/av A. . COMPLETED cams/201 5 ST RESIDENTIAL CARE HOME NAME OF PROVIDER OR SUPPLIER STREET ADDRESS STATE, ZIP CODE 243 NORTH PROSPECT STREET BURLINGTON: VT 05401 - (Xe) Io SUMMARY STATEMENT or: . DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY DR LSC IDENTIFYING m5 Pnovioen's PLAN OF co nnecrron he} (EACH CORRECTIVE ACTION SHOULD BE COMPLETE - CROSS-REFERENCED TO THE APPRO PRIATE DATE DEFICIENCY) R266 Continued From page a e255 for Vermont Cathoric Charities stated that although discussions were had by administration 2 about a solution to the security of residents, there had been no ?nal decision as to what system would be installed to better secure the home. 1 Per interview on SIZSHS at 9:55 AM, the Director of Nursing Services identi?ed two current residents with dementia who were considered at risk for elopement. One of them resided in a room on the ground floor thatwas close by and easily accessible to an exit that had no alert system on it to indicate someone had exited the i door. The DNS stated that there were always two awake staff working the overnight shift. and they compieted rounds of the building less than an hour before Residentirt exited the door on the i 2 night of and found the residentin their room at that time. The DNS also confirmed that 5 although the staff are awake and checking on residents: the possibility still existed for a resident to exit undetected by staff if they were in another part of the building at the time. naos ix. PHYSICAL PLANT 1; R303 sese a 9.11 Disaster and Emergency Preparedness 9.11d There shall be an operable telephone on 2 each floor of the home, at all times. A list of emergency telephOne numbers shall be posted by each telephone. This REQUIREMENT is hot met as evidenced by: 3. Based on observation and staff interview, the - home failed to ensure that an operable telephone . was available on each floor of the home with a list i R303 IX Physical Plant: On the day of survey? 3/23/15? upon notification of noncompliance with the state Regulation 9.11, phones were immediately placed in public areas. One on each floor as required by the regulation. The phones will remain in place and emergency phone numbers are posted next to the phones for easy access. Division of Licensing and Protection FORM cu: 02KW11 ir continuation sheet 7 or 10A a aura iUiJ?J?i? ruruurl 04l03l2015 FORM APPROVED DivisiOn of Licensinq and Protection 1 STATEMENT OF DEFICIENCIES (X1) {x2} MULTIPLE CONSTRUCTION DATE 8URVEY AND PLAN OF CORRECTION A COMPLETED 9155 5- 0312312015 NAME OF PROVIDER on SUPPLIER STREET ADDRESS. crw. STATE. ZIP was 243 NORTH PROSPECT STREET ST A CARE HOM BURLINGTON. VT 05401 (X4) in SUMMARY STATEMENT or DEFICIENCIES Pnomoee's PLAN OF CORRECTION (x5) PREFIX DEFICIENCY mus'r sE PRECEDED BY FULL (EACH CDRRE CTIVE AC SHOULD BE COMPLETE TAG ceoss-nerensnceo TO THE APPROPRIATE DATE TAG REGULATORY DR LSC Division of Licensing and Protection STATE FORM R303 Continued From page 7 of emergency phone numbers. Findings inciude: Per observation during a tour of the home on 3/2311 5, there were no terephones visible on the two upper floors of the home where residents reside Per interview on 3f23f15 at2240 PM, the manager of the home canfirmed that the telephones on the two upper floors had been removed due to a resident repeatedly ceiling 911 Emergency Services for non?emergent reasons. The Manager confirmed that a wireless telephone; was available to residents if they asked staffto use it} however there was no phone available on the upper two home with a list of emergency phone numbers as perthe regulation. i M.vu .- - . .. -. R303 was 02m? if continuation sheet 6 of a