The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

PORTER HOSPITAL, INC 115 PORTER DRIVE MIDDLEBURY, VT 05753 Dec. 31, 2013
VIOLATION: PROVISION OF SERVICES Tag No: C0270
Based on record review and staff interviews the Condition of Participation for Provision of Services is not met as evidenced by:

The CAH failed to assure that care and services were provided in accordance with established policies and procedures. Refer to C-0271

The CAH failed to assure nursing conducted ongoing reassessments of a patient's condition. Refer to C-0296
VIOLATION: PATIENT CARE POLICIES Tag No: C0271
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interviews and record review the facility failed to assure care and services were consistently provided in accordance with established policies and procedures for 2 patients. (Patients #1 and #8). Findings include:

1. Per review the facility's policy, Abuse - Elderly or Disabled, dated March of 2013, stated; "As per Vermont State statute all health care practitioners are required to report suspected abuse, neglect or exploitation of the elderly or disabled adult within 24 hours....III. Procedure: A. Suspected abuse.....of elderly or disabled adults; reports..1. Any of the following individuals having received information of abuse.........shall report or cause a report to be made within 24 hours:...a. all employees, contractors and grantees of the Agency of Human Services who are involved in caregiving, a physician.....mental health professional, social worker...B. It is the responsibility of the nurse or social worker to report to the Nursing Office and to the following agency: Adult Protective Services. The policy also identifies; "B. Indicators of possible abuse;....1. Physical Abuse: a. Any patient who reports an abusive incident..."
Per record review, conducted on 12/30/13, staff failed to report an allegation of patient mistreatment by staff to the appropriate State Agency (SA), in accordance with their policies and procedures. Patient #1 presented to the ED (Emergency Department) on 11/8/13 with an acute psychiatric condition and spent 5 days in the ED while awaiting involuntary bed placement to an available inpatient psychiatric unit. The patient had a psychological consult by a QMHP (Qualified Mental Health Professional), dated 11/13/13, that indicated, "[s/he] is mistrustful of staff, worrying that [s/he] is being poisoned, as well experiencing unwanted sexual activity." The note further stated "(these are not happening)."
Per interview, at 11:29 AM on 12/13/13, the ED Nurse Manager stated the facility had not been aware of the allegation of sexual misconduct against Patient #1 by staff until notified by APS on 11/15/13. The Nurse Manager stated that once they were made aware an investigation was conducted. S/he further stated s/he was not aware of any notification by the QMHP to staff regarding the allegation made by Patient #1 on 11/13/13, and indicated that s/he would expect any contracted personnel providing services to patients to report to staff any allegation of mistreatment.
During interview, at 2:31 PM on 12/31/13, the acting CNO (Chief Nursing Officer) stated that the facility has a contract with a local organization that provides psychological/psychiatric services for patients, and members of that organization who provide services to patients in the facility are expected to provide those services in accordance with the facility's established policies and procedures. The acting CNO further stated that the QMHP should have reported Patient #1's allegation of sexual misconduct to the ED provider or nurse.

2. The facility's policy regarding Patient Rights and Responsibilities, dated October, 2013, stated "...It is the responsibility of every employee to ensure the patient's rights are maintained." It further stated; "As a Patient You Have the Right:....To refuse treatment to the extent permitted by law - including declining or withdrawing life-sustaining treatment or resuscitation measures, and to be informed of the medical consequences."

Per record review, conducted on 12/30/13, Patient #1 presented to the ED (Emergency Department) on 11/8/13 at 7:02 PM, with an acute psychiatric condition. A nurse's note, dated 11/8/13 indicated the patient was restrained using Twice as Tuff cuffs to both wrists and ankles, at 9:45 PM on that evening, related to aggressiveness and ongoing threats of harm to others. A subsequent note, at 10:07 PM stated the "Patient was restrained with Ativan, per order." The record indicated the patient received 2 mg of Ativan IM (intramuscularly) at that time. Patient #1 remained in 4 point restraints, with 1:1 observation by staff, and a note at 11:30 PM stated; "Pt refused Vital Signs The patients respirations are regular, The patients skin is Pink warm, and dry, patient threatening to harm others." A subsequent note, at 11:45 PM indicated that the patient refused to take Zyprexa (antipsychotic) orally and was informed by staff that if s/he "did not cooperate with the plan of care the medication would be administered IM." The note further stated, "States that s/he wants to do what ever it takes to 'Get the hell out of here'.....Pt took medication orally." The patient received 10 mg of Zyprexa PO (by mouth) at 11:45 PM. A physician note, dated 11/9/13 at 1:32 AM, stated that the patient was "somewhat calmer after 2 mg IM Ativan, agree to take 10 mg PO Zyprexa after told we were going to administer IM."

Despite the patient's initial refusal to take the Zyprexa at 11:45 PM, s/he did accept it orally, however, only after being informed that it would be administered IM if not taken PO.

During interview, at 2:31 PM on 12/31/13, the acting CNO (Chief Nursing Officer) confirmed that patients do have the right to refuse treatment. S/he also acknowledged that telling the patient if s/he did not agree to take a medication orally, it would be administered IM, could be perceived by the patient, whose wrists and ankles were already restrained, as threatening or intimidating.

3. Per review, staff failed to provide ongoing reassessment of a patient's condition, including vital signs, in accordance with established policies and procedures. The facility policy, Emergency Department Triage Policy and Procedure, dated February, 2013, stated the following: for a triage ESI (Emergency Severity Index) level of 3 (conditions that could potentially progress to a serious problem requiring emergency intervention. May be associated with significant discomfort or affecting ability to function at work or activities of daily living), reassessment should be conducted every 30 minutes. The policy further stated; "1. There should be a nursing reassessment on all patients at the time intervals recommended for practitioner assessment. This is to ensure that patients are reassessed to confirm that their status has not changed. Reassessment will include documentation of the patient's vital signs."

Per record review Patient #8 (MDS) dated [DATE], at 5:10 PM, complaining of anxiety with symptoms including nausea and feeling jittery. At the time of triage, at 5:13 PM, the patient's BP (blood pressure) was elevated at 160/90 and his/her ESI was assessed as a level 3 (urgent). The patient was given Ativan 1 mg PO (by mouth), at 5:49 PM and although a re-evaluation was conducted, by the provider, at 6:30 PM and the patient had stated that s/he felt much better, there was no evidence that the patient's BP had been reassessed prior to discharge at 6:40 PM.
During interview, at 2:31 PM, the acting CNO (Chief Nursing Officer) confirmed the lack of reassessment of Patient #8's BP and stated that staff had not reassessed the vital signs in accordance with the policy and procedure.
VIOLATION: NURSING SERVICES - SUPERVISION OF CARE Tag No: C0296
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and confirmed through staff interviews staff failed to conduct ongoing assessments of a patient who presented to the ED (Emergency Department). (Patient #8). Findings include:

Per record review Patient #8 (MDS) dated [DATE], at 5:10 PM, complaining of anxiety with symptoms including nausea and feeling jittery. At the time of triage, at 5:13 PM, the patient's BP (blood pressure) was elevated at 160/90 and his/her acuity was assessed as a level 3 (urgent). The patient was given Ativan 1 mg PO (by mouth), at 5:49 PM and although a re-evaluation was conducted, by the provider, at 6:30 PM and the patient had stated that s/he felt much better, there was no evidence that the patient's BP had been reassessed prior to discharge at 6:40 PM.
During interview, at 2:31 PM, the acting CNO (Chief Nursing Officer) confirmed the lack of reassessment of Patient #8's BP and stated his/her BP should have been re-assessed prior to discharge.