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 | Jan. 22, 2020 |
| VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES | Tag No: A0283 | |
| Based on record review and staff interviews, the facility failed to assure that events that affect patient outcomes and the quality of care were identified and communicated to the patient in 1 of 6 Emergency Department records reviewed. Findings include: Based on record review, Patient # 1 had a fall on 9/6/19 that resulted in lacerations on the right forehead and the right ring finger. The patient was transferred to the emergency room via ambulance for treatment and arrived at 1:12 AM. Sutures were required to treat the lacerations. X-rays were obtained of Patient # 1's right hand in addition to a chest X-ray, CT scan ( procedure which x-rays cross sections of tissue) of the cervical spine and the head. The ED physician's notes stated that Patient #1's lacerations were located on the right third finger, described as being a three centimeter laceration on the volar surface and a one centimeter laceration on the medial aspect of the distal phalanx (fingertip). This was in addition to a three centimeter laceration on the right forehead. The notes also stated the patient had full extension of the right third finger with no deformities. The physician documented that imaging reports were reviewed and independently interpreted. The physician notes stated " Patient had a right hand x-ray, which was significant for no acute fracture or foreign body of the right 3rd finger" and "...."Imaging was obtained, reviewed, and interpreted by myself and radiologist. Please see radiology report for further details." The radiology clinical history/comments dated 9/6/19 for Patient #1 stated "fell , 3 centimeter laceration on ring finger." The findings stated "There is a nondisplaced crush fracture of the distal phalanx (tip of finger) on the right 4th finger. Bandage material is seen around the ring finger. There is no radiopaque foreign body. There is a difference between this interpretation and that provided by the preliminary resident report which requires non-urgent notification. The findings were telephoned ot (spelling error in report) the ED at 10:30 AM. " There was no documentation in the ED record who received the the updated interpretation from radiology, if the treating physician was notified or if the patient was notified. Patient # 1 was discharged from the ED on 9/6/19 at 10:28 AM. The discharge information stated there was no fracture present. Patient # 1 was discharged with orders for pain medication and an antibiotic. During interview and record review on 1/22/20 at 2:00 PM with the ED physician who treated Patient #1 on 9/6/19, the physician stated "I had already left when radiology called. The patient was nearing discharge or had already left. Not sure who was given x-ray results. Normally radiology documents who they spoke to." The ED physician who also represents the ED for the hospital's Quality Department, was unsure if radiology notified Patient #1 after h/she was discharged and "would follow up and check with them." |
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| VIOLATION: OPERATING ROOM POLICIES | Tag No: A0951 | |
| Based upon interview and record review, the facility failed to ensure policies governing surgical services, as they pertain to color blindness testing, were consistently implemented in accordance to standards of practice for 1 of 3 Operating Room (OR) staff. Per interview with Human Resources (HR) staff and confirmed on 1/22/20 at 3:03 PM, there is no evidence that Surgical Technician (ST) #1 had the required color blindness test done since date of hire on 5/8/95. HR first notified ST #1 on 10/31/17 that she/he was required to have the color blindness test done; HR sent a 2nd notification to ST #1 on 12/11/17; HR send a 3rd notification on 1/15/18, which included the Supervisor. The color blindness test was not done following the 3 notifications sent by HR to ST #1. No additional follow up with ST #1 or the Supervisor was done by HR. In addition, HR confirmed that OR Tech #1's job description includes that color blindness testing be done. Per record review of "Job Title: Surgical Technician, Job Code 079N"; created 10/29/18, Version 2, the sensory functions required for this job include Color Vision. |
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| VIOLATION: INTEGRATION OF EMERGENCY SERVICES | Tag No: A1103 | |
| Based on record review and staff interviews, the facility failed to assure that services were integrated between Radiology and the Emergency Department (ED) in 1 of 6 ED records reviewed. Findings include: Based on record review, Patient # 1 had a fall on 9/6/19 that resulted in lacerations on the right forehead and the right ring finger. The patient was transferred to the Emergency Department for treatment and arrived at 1:12 AM. Sutures were required to treat the lacerations. X-rays were obtained of Patient # 1's right hand in addition to a chest X-ray, CT scan ( procedure which x-rays cross sections of tissue) of the cervical spine and the head. The ED physician's notes stated that Patient #1's lacerations were located on the right third finger, described as being a three centimeter laceration on the volar surface and a one centimeter laceration on the medial aspect of the distal phalanx (fingertip). This was in addition to a three centimeter laceration on the right forehead. The notes also stated the patient had full extension of the right third finger with no deformities. The physician documented that imaging reports were reviewed and independently interpreted. The physician notes stated " Patient had a right hand x-ray, which was significant for no acute fracture or foreign body of the right 3rd finger" and "...."Imaging was obtained, reviewed, and interpreted by myself and radiologist. Please see radiology report for further details." The Radiology report dated 9/6/19 for Patient #1 stated "fell , 3 centimeter laceration on ring finger." The findings stated "There is a nondisplaced crush fracture of the distal phalanx (tip of finger) on the right 4th finger. Bandage material is seen around the ring finger. There is no radiopaque foreign body. There is a difference between this interpretation and that provided by the preliminary resident report which requires non-urgent notification. The findings were telephoned ot (spelling error in report) the ED at 10:30 AM. " There was no documentation in the ED record who received the the updated interpretation from radiology, if the treating physician was notified or if the patient was notified. Patient # 1 was discharged from the ED on 9/6/19 at 10:28 AM. The discharge information stated there was no fracture present. Patient # 1 was discharged with orders for pain medication and an antibiotic. During interview and record review on 1/22/20 at 2:00 PM with the ED physician who treated Patient #1 on 9/6/19, the physician stated "I had already left when radiology called. The patient was nearing discharge or had already left. Not sure who was given the x-ray results. Normally radiology documents who they spoke to." The ED physician was unsure if radiology notified Patient #1 after h/she was discharged and stated h/she "would follow up and check with them." |
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