A Burlington nursing home failed to provide adequate care to residents during an outbreak that affected 127 residents and staff, according to federal regulators.
The Centers for Medicare and Medicaid Services reported this week that residents at Elderwood at Burlington were left to sit in their own urine, and didn’t receive required medications or proper wound care as Covid swept through the facility last month.
Employees reported similar concerns to VTDigger at the time. Staff worked to the point of exhaustion and were spread too thinly to respond to call buttons or make sure that residents were bathed and fed properly, they said.
The surprise investigation, first reported by Seven Days, was sparked after five staff complaints. Regulators visited the home on Dec. 9 and 10, at the height of the outbreak.
Inspectors found widespread violations. In one of the more egregious instances, staff didn’t change the dressing for an ulcer on at least five different occasions. The stage 4 ulcer, a sore that typically reaches deep into tissue or to the bone, was supposed to be checked every week; it wasn’t assessed for nearly five weeks, according to the report from the Centers for Medicare and Medicaid Services.
On Dec. 2, about a dozen residents did not receive prescribed medication, according to the report. One resident didn’t get scheduled doses for congestive heart failure; others missed medication to treat high blood pressure and insulin for diabetes.
One resident’s family member complained that the relative hadn’t received heart meds. “Management made aware,” staff noted at the time.
Inspectors found that Elderwood staff didn’t respond to a call light for 45 minutes, causing the resident who needed to use the bathroom to leak urine. Another resident told inspectors that nurses hadn’t emptied a urinary catheter bag regularly. A family member said in an interview with federal officials that the relative was “left in bed for 14 days” without assistance to get up.
In response to the report, Elderwood promised to “reeducate” nurses and review medication protocols, according to the corrective action plan. The facility also fired one nurse who hadn’t provided medication.
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“The facility continues to hire, train and schedule enough competent staff to meet the needs of residents and adhere to federal regulations,” Elderwood said in the plan of correction. Facility officials did not explain how the corrective action plan would be implemented.
“Elderwood at Burlington provides safe, quality care for all of our residents,” said spokesperson Chuck Hayes in a written statement. “We work collaboratively with the state regulatory authorities to appropriately identify and address any and all potential areas for improvement. As always, our primary focus continues to be the health and well-being of our residents.”
Hayes did not respond to follow-up questions. He said he was “unable to provide details on personnel issues.”
After Elderwood reported the first positive case on Nov. 24, the virus spread rapidly, engulfing much of the facility. More than 80 residents came down with the virus out of a total of 107. Now, there are 85 residents at the facility, Hayes said.
More than three dozen staff members also tested positive, leaving the facility with few workers to provide care for residents with Covid. At several times, only two licensed nursing assistants were left to care for two dozen residents, an employee told VTDigger in December.
Nurses are trying “to feed two meals, and [respond to] call lights, incontinent care, bedsore care, you name it. It can’t be done,” she said.
Nursing homes nationwide report staffing shortages during the best of times. Covid has further strained recruiting. When the virus hit Elderwood, the state tried to mitigate the shortages by recruiting volunteers and workers from the University of Vermont Medical Center.
Officials from the state Department of Health and the Department of Disabilities, Aging and Independent Living defended the facility’s response to the outbreak. “There were no red flags, no evidence of something that could have been prevented or could have done better,” Kayla Donohue, head of the Department of Health’s rapid response team, said in early December.
Hayes told VTDigger the staffing challenges didn’t affect patient care. “Do we have concerns about safety and care? No. Are people working harder because of this? Yes, they are.”
The facility also failed to notify family members of new Covid cases in a timely manner. A federal rule requires that nursing homes tell family members of new cases by the following day. At one point, the facility didn’t provide updates for six days, the federal investigation found.
“It’s pretty bad when you have to hear it on the news or newspaper,” a family member said in an interview with inspectors.
The state Department of Disabilities, Aging and Independent Living is responsible for making sure Elderwood addresses the issues raised in the federal report. The department will “verify that substantial compliance has been achieved and maintained,” licensing chief Pam Cota wrote to the facility this week.
Employees have reported other complaints that weren’t mentioned in the report. Some said they weren’t fit-tested for N95 masks until after the first case. One said she didn’t receive the training she needed.
Several workers told VTDigger that the facility had not paid employees for their time off after they tested positive for Covid; paying for sick time is not required under federal law for nursing homes. A few said they’d apply for financial aid, to help pay for rent while they were sick.
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