State Finds Violations at Mt. Ascutney
Windsor — A recent surprise inspection by the state found that Mt. Ascutney Hospital didn’t take adequate measures to prevent a terminal cancer patient from falling six times in six weeks and failed to respond to another dying patient’s request to limit treatment to comfort measures.
The Dec. 9 inspection also found the Windsor hospital didn’t document the need to use restraints on another patient prone to falls.
The Vermont Division of Licensing and Protection on Tuesday accepted the hospital’s plan of correction.
“Taking care of safety and appropriate documentation are of the utmost importance to us,” Mt. Ascutney Hospital and Health Center Chief Executive Kevin Donovan said Thursday.
The inspection report detailed several lapses by the hospital.
A patient who was admitted on July 1 suffering from end-stage lymphoma was assessed to be at a high risk of falling, but the hospital failed to put in place a prevention plan and he or she fell from a wheelchair or bed six times while delirious, confused or in pain, the report said. The hospital also failed to properly document four of the falls.
The hospital failed to properly assess the fall risks of a patient who recently had suffered a stroke, document the need for restraints that were used three times to prevent him or her from falling and disclose in its record of one fall that a bed alarm was not in place, the report said.
The hospital also failed to put in place a care plan that reflected the wishes of a third patient who had been admitted in November and treated for heart failure, the report said: “There was no indication in the care plan that (the patient) was transitioned to receive only comfort measures, including adequate symptom management and provision of family support during the patient’s final days.”
The report spelled out deficiencies in the hospital’s patient care policies, nursing services, records systems and quality assurance programs. All of the deficiencies were judged to have been widespread, with the potential for minimal harm, but not to have caused actual harm.
The hospital’s correction plan commits the facility, which is affiliated with Dartmouth-Hitchcock, to beef up care planning, assessments of patients’ fall risks, training and record-keeping when falls occur or restraints are used.
The patients who received the deficient care identified by state inspectors occupied swing beds, Donovan said.
Swing beds are beds in an acute care hospital that also can be used for patients receiving rehabilitation or so-called sub-acute care. Swing bed care generally is paid for at a lower rate than acute care.
Mt. Ascutney is a 25-bed hospital with critical access designation from the U.S. Centers for Medicare and Medicaid Services, which entitles the facility to elevated compensation for the care it provides to patients covered by Medicare. A majority of patients at Mt. Ascutney are covered by Medicare, Donovan said.
Rick Jurgens can be reached at rjurgens@vnews.com or 603-727-3229.
