August 3, 2015 Ms. Mary Belanger, Manager St Joseph's Residential Care Home 243 North Prospect Street Burlington, VT 05401?1609 Dear Ms. Belanger: 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 Enclosed is a copy of your acceptable plans of correction for the survey conducted on July 6, 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, Siam/WM Pamela M. Cota, RN Licensing Chief 07-31 15 14:52 FROM- Division_ol'vLicensind and Protection St Joseph Home Burl 8028845840 T-582 I IUILU hJ FORM APPROVED STATEMENT OF DEFICIENCIES (Xi) PROVIDERISUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 0155 (X2) MULTIPLE CONSTRUCTION A. BUILDING: WING SURVEY COMPLETED 0710612015 NAME OF PROVIDER CIR SUPPLIER ST RESIDENTIAL CARE HOME ADDRESS. CITY. sTAre. ZIP CODE 243 NORTH PROSPECT STREET BURLINGTON, VT 05401 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY DR IDENTIFYING INFORMATION) DEFICIENCY) ID Friedman's PLAN OF CORRECTION {its} PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG To THE APPROPRIATE DATE R126 R100 Initial Comments: An unannounced Uri?site Complaint investigation was conducted on 716! 15 by the of Licensing and Protection. The following regulatory violations were identified. V. RESIDENT CARE AND HOME SERVICES 5.5 General Care 5.5.3 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 interview and record review the home failed to meet the identified safety care needs for 'l of 2 residents reviewed. (Resident Findings include: - Per record review and despite the fact that Resident who was admitted to the home on SIIHS. had exhibited elopement behaviors in the early morning hours of Bleii? indicating a high risk safety concern. the home failed to implement an adequate plan to assUre the ongoing safety of the resident who elooed again 4 days later and sustained significant injury. A nurse's note. at 6:45 AM on 6/4115. indicated that. despite the alarm System on all exit doors. Resident #1 had been found in the parking lot. outside the home at approximately 4:40 AM that morning, after she had rung the doorbell attempting to enter the home The note stated that the residentwas very R128 Division of Licensing and Protection LABORATORY DIRECTOR 8 OR PROVIDERISUPPLIER REPRESENTATIVES SIGNATURE TITLE MAX flu??x madam (XE) DATE Wadi/5' licon/tinuation sheet 1 0M 073-313 I5 ?1:53 St Joseph Home Burt 8028845340 T-BBQ 0 i?Hli?i I EU: UH Idl'xL'U IO . . FORM APPROVED ?icensino and Protection .. STATEMENT OF DEFICIENCIES (Xi) (x2) MULTIPLE CONSTRUCTION {its} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED - .. - -. 0155 31?? 07/06/2015 NAME or PROVIDER oR SUPPLIER ST RESIDENTIAL CARE HOME STREET mosses. CITY, STATE, ZIP code 243 NORTH PROSPECT STREET . VT 05401 R256 confused at the time and reported to staff that s/he had been trying to get into cars. Another nurse's note, 4 days later on 6/8/15 at 6:55 AM, stated that Resident #1 was observed sleeping in- his/her room at 1:15 AM that morning and noted to be missing from his/her room at approximately 3:15, AM. The note further stated that all door alarms had been on but not heard by anyone. The resident was subsequently found Off the home?s property by police, was transferred to the ED (Emergency Department) with significant injuries and died approximately 2 - 3 Weeks later. During interviewboth the home's Administrator and DNS (Director of Nursing Services) acknowledged the home's awareness that the door alarm system had failed to alert staff of Resident #1 's exit from the home in'the early morning hours of 6/4/15. The DNS stated that although the door alarm security system had failed to alert staff to the resident's exit the system had not been replaced at that time. S/he indicated. that the only additional plan implemented to assure a safe environment for Resident #1 was for staff to conduct safety checks on an hourly basis1 however, despite this the resident was still able to exit the home, once again, without staff knowledge. The Administrator stated that, despite the second eicpement and subsequent injury to Resident #1 on 6/3/15, 3 new security system had not'been installed until recently and it was first up and running on the afternoon of survey on 7/6/15. *This is a repeat deficiency IX. PHYSICAL PLANT R126 R266 so) In seams? STATEMENT or DEFICIENCIES ID PLAN oF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE COMPLETE mo neeuwoav oR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DATE . DEFICIENCY) R128 Continued From page 1 As of July 6. 2015, as witnessed by State Survey Norse, ST. Joseph?s Residential Care Home has installed a door alarm system. This system automatically arms at 9:00pm and disarms at 5:00 am. if any door in the building is breached between those hours, the following sequence of events occurs: 1. The keypads by the front dom and by the kitchen/smokers doors: the alarm monitoring company is alerted automatically. 2. The alarm company calls the Nurse/Med Tee ?3 Cell phone number. If they answer- they inform the nurse which door has?been breached and asks for a code to descrivate the stem 3. If they do not answer the LNA/Caregiver is called on their cell phone 4. If no answer the alarm company calls the house phone, 5. If no answer. then 91 1 is called and 6. The Administrator is called Once staff is netified, they immediately investigate to see who breached the door. The call process should not take more than 253 minutes at most. The staff is told the specific door that was breached and is able to do a search in the specific location quickly. If resident is not located after an external and internal check, 911 is called immediately. PCC. drug-hi ?i3ilS Bums/2M Division of Licensing and Protection STATE FORM 6599 sheet 2 ofd 07?31 15 14:53 St Joseph Home Burl 8028845840 T-582 CI F-74i i ELL UH romu . FORM APPROVED of Licensing and ProteCtioermm STATEMENT OF DEFICIENCIES (x1) (x2) MULTIPLE CONSTRUCTION . (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 0155 3- 0710?1201 5 NAME OF PROVIDER on so STREET ADDRESS, STATE, ZIP CODE 243 NORTH PROSPECT STREET - 3T 03 EPH 3 RESIDENTIAL CARE HOME BURLINGTON, VT 05401 (x4; Io so MMARY STATEMENT or ID PLAN OF CORRECTION as) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION snouto as COMHETE TAG REGULATORY OR INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE R266 Continued From page 2 R233 9.1 Environment tile The home must provide and maintain a safe, functional. sanitary. homelike and comfortable environment. This REQUIREMENT is not met as evidenced by: Based on observation. staff interviews and record review the home failed to assure a consistently safe environment for one at risk resident. (Residentilt?l). Findings include: Per record review and despite the fact that Resident who was admittedto the home on 6r1r15,'nad exhibited elopement behaviors in the earlymorning-hours of 614/15, the home failed to implement an adequate plan to assure the Ongoing safety of the resident who eloped again 4 days later and sustained signifioant self injury. A nurse's note. at 6:45 AM on 6/4116, indicated that, despite the alarm System on all exit doors, Resident#1 had been found in the parking lot. outside the home at approximately 4:40 AM that moming, after slhe had rung the doorbell attempting to enter the home. The note stated that the residentwas very confused at the time and reported to staff that sihe had been trying to get, into cars. Another nurse's note, 4 days later on at 6:55 AM, stated that Resident #1 was obServed sleeping in his/her room at 1:15 AM that morning and noted to be missing from his/her room at approximately 3:15 AM. The note further stated that all door alarms had been on but not heard byenyone, The residentwas subsequently found off the home's property by police, was transferred to the ED (Emergency Department) with significant injuries and expired approximately 2 3 weeks later. Division of Licensing and Protection STATE FORM 'ioorm If continuation sheet 3 0M [Ti-81 15 14:54 Division of Licensing and Protection St Joseph Home Burl 8028845840 T-582 001 0 I l?ur Uff 3U FORM APPR OVED During interview both the home's Administrator and DNS (Director of Nursing Services) acknowledged the home's awareness that the door alarm system had failed to alert staff of Resident #i's exit from the home in the early morning hours of 6/4/15. The DNS stated that although the door aiarm security system had failed to alert staff to the resident's exit the system had not been replaced at that time. S/he indicated that the only additional plan implemented to assure a safe environment for Resident #1 was for staff to conduct safety - checks on an hourly basis, however, despite this the residentWas still able to exit the home, once again, without staff Knowledge. The Administrator stated that, despite the second elopement and ?subsequent injury to Resident #1 on 8/8/15, a new security system had notbeen installed until recentiy and it was first up and running on the afternoon of survey on 7/6/15. ?This is a repeat deficiency Division of Licensing and Protection STATE IFORM STATEMENT OF DEFICIENCIES (x1) (X2) MULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF NUMBER: A. BUILDWG, - COMPLETED . . 0155 Bi WING .. a ortostgogs NAME OF PROVIDER on suppose STREET CITY, STATE, ZIP cooe 243 NORTH PROSPECT STREET ST RESIDENTIAL CAR 0 - ME BURLINGTON, VT 05401 (X4) to 7 SUMMARY seamstress Io psoixioEn-s'n'tjiN or: txsi' PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY oR Lse IDENTIFYING IN FORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE DEFICIENCY) R266 Continued From page 3 R263 As of July 6, 2015, as witnessed by State Servey Nurse, ST. Joseph?s Residential Care Home has installed a door alarm system. This system automatically arms at 9:00pm and disarms at 5:00 am, If any door in the building is breached between those hours, the following sequence of events occurs: 1. The keypads by the front door and by the kitchenfsmolters doors; the alarm monitoring company is alerted automatically. 2. The alarm company calls the Nurse/Med Tech?s Cell phone number. If they answer~ they inform the nurse which door has been breached and asks for a code to deactivate the alarm 3. If they do not answer the LNA/Csregiver is called on their cell phone 4. If no answer the alarm company cells the house phone, 5. If no answer, then 911 is called and 6, The Administrator is called Once staff is noti?ed, they immediately investigate to see who breached the door. The call process should not take more than 2-3 minutes at most. The staff is told the speci?c door that was breached and is able to do a search in the speci?c location quickly. If resident is not located s?or an external and internal check, 911 is called immediately. This system was installed by Life Safety Systems. They also provide weekly testing of the system. There is also a green check mark on both the panels to indicate that the system is activated. Staff was trained by either the installer or the DNS. New staff are trained as part of their new hire orientation. Attached are the instructions that are posted as a reference for all nursing staff. Raw Pct. stalls his 87881 ??l5 14:54 FRUM- St Joseph Home Burl 8828845848 T-582 P0808/80l0 F-74l Door Alarm System procedure July 6, 2015 All exterior doors are alarmed and connected to our Home Security provider; sometimes referred to as Central Station. This system will automatically arm (turn on) at 9:00pm and disarm (turn off) at 5:00am. There are two keypads in the building; one at the front door, the other at the smoker?s door. These are the ONLY doors that evening and night shift can use to enter and exit the building. When entering the building after 9:30pm, staff members must disarm the system to prevent the alarm from going off. To do this: Enter through the front door or smokers 1. Go immediately to the key pad. ?One is located on the wall inside the interior door at the smoker?s entrance. -The other is located on the wall inside the door at the top of the stairs at the front door. 14:55 FROWF St Joseph Home Burl 8028845840 T-582 2. Enter your code and press enter -currently everyone?s code is 243. This will disarm the alarm. The alarm will reset itself in 30 seconds. This code is con?dential and should not be shared with any residents. To exit the building after 9:30pm and before 5:00am 1. ?Go to either the front door or the smoker?s door. 2. Enter the code and press enter. Leave the building immediately to prevent the alarm from going off. 3. The alarm will reset in 30 seconds. If a resident leaves the building between the hours of 9:30pm and 5:00am, the system will alarm. The panels at the front door and smokers doors will alarm. It is unlikely you will hear those alarms. (If you do, disarm the system using the code and call the alarm company to avoid a false alarm) This will send a signal to home security/central station. Within 1 minute of receiving the call, they will do the following: 1. Call the med tech?s cell phone?if not answered 2. Call the care givers cell phone?if not answered 3. Call the house phone-if not answered 4. Call 911? to be sent out and 14:55 FROM- Joseph Home Burl 8028845840 T-EBZ P001 0/0010 Fw74l 5. Call Mary Belanger to notify of situation. When/if the call is answered by a staff member, they Will be told that the alarm is going off and What door was triggered. This will enable staff members to immediately go to that door and locate the resident that left the building. The doors are referred to and labeled as follows: l.Front door 2.. Smoker?s door 3. Parking lot door 4. Bus parking door 5. Cemetery door 6. Dining room door 7. Delivery/ramp door