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.
|UNIV. OF VERMONT - FLETCHER ALLEN HEALTH CARE||111 COLCHESTER AVE BURLINGTON, VT 05401||Feb. 26, 2019|
|VIOLATION: NURSING CARE PLAN||Tag No: A0396|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on staff interview and record review, the hospital failed to ensure that nursing staff developed a care plan to address each of current care needs for 1 of 10 patients in the total sample. (Patient #1). Findings include:
Per review of the medical record for Patient #1 on 2/25/19, there was no care plan to address the patient's nightly use of a CPAP (Continuous Positive Airway Machine) treatment of a medical condition known as Obstructive Sleep Apnea. The patient was admitted to the hospital's inpatient acute rehab unit for services on 1/31/19 and discharged on [DATE]. During interview on 2/26/29 at 11:12 AM, a Registered Nurse (RN) who had provided care to the patient on the evening shift stated that s/he had seen the CPAP in the patient's room on the evening shift on 2/1/19 and it was set up on the following day. The RN confirmed that the patient, who was post CVA (cerebral vascular accident), needed physical assistance to properly place the mask on their face for treatment. Per review of the care plan (2/26/19) there was no nursing plan to address the patient's use of the CPAP nightly treatments, including RN review of the machine for correct settings and water reservoir level, and placing the face mask. The lack of the nursing plan to address this need was confirmed with the RN and the Unit Nurse Manager at the conclusion of the interview.