A recent surprise inspection by the state revealed numerous lapses by Mt. Ascutney Hospital, a critical access facility based in Windsor, Vt., according to a Valley News report.
Here are five things to know about the inspection and its findings.
1. The inspection, conducted Dec. 9 by the Vermont Division of Licensing and Protection, found Mt. Ascutney failed to take adequate measures to prevent a terminal cancer patient from falling six times in six weeks, according to the report. The hospital determined the patient, who suffered from end-stage lymphoma, was at a high risk of falling. However, the hospital did not put a prevention plan in place and the patient fell from a wheelchair or bed six times while delirious, confused or in pain, according to the report. The hospital also didn't properly document four of the falls.
2. The inspection also revealed Mt. Ascutney did not properly determine the fall risks of a patient who recently had suffered a stroke, according to the Valley News, and failed to document the need for restraints that were used three times to prevent this patient from falling. Furthermore, the hospital didn't disclose in its record that a bed alarm was not in place during one of this patient's falls.
3. Additionally, the state found the hospital did not put a care plan in place that reflected the wishes of a third patient who had been admitted in November and treated for heart failure, according to the report. "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 state said, according to the Valley News.
4. Overall, the state noted Mt. Ascutney had deficiencies in its patient care policies, nursing services, records systems and quality assurance programs, according to the report. The state determined these deficiencies had the potential for minimal harm, but "not to have caused actual harm," the report notes.
5. In light of the state's findings, the hospital has made a plan for correction. Under the plan, Mt. Ascutney has committed to beefing up care planning, assessments of patients' fall risks, training and record-keeping when falls occur or restraints are used, according to the report.