Vermont Healthcare Center: Pressure Ulcers, Staffing - CA

Resident 154, who was admitted with cerebral infarction and functional quadriplegia, required total assistance with daily activities and was at high risk for pressure injuries. Her care plan specifically called for repositioning every two hours and daily skin inspections by nursing assistants.

But records show massive gaps in her care. From February 11 through February 28, documentation reveals she was not turned every two hours on multiple days. On some days, staff recorded only two or three position changes instead of the required 12.

The consequences were predictable. On February 25, staff discovered a deep tissue injury measuring 2.5 centimeters by 2.0 centimeters on her right foot. Two weeks later, on March 11, another injury appeared on her right buttock, measuring 3.5 centimeters by 1.5 centimeters.

Treatment Nurse 1 acknowledged the injuries could have been prevented. "Resident 154's pressure injury to the right lateral foot and right buttock could have been avoided if the resident was turned every two hours and if Prevalon boots were applied on admission," he told inspectors.

The facility also failed basic hygiene protocols. Resident 154 was scheduled for showers on Tuesdays and Fridays, but records show she received only two showers between her January admission and early March. On eight separate scheduled shower days, no skin inspection sheets were completed, indicating she received neither showers nor bed baths.

"Missing Resident 154's Skin Inspection sheets indicated Resident 154 did not receive a shower on her scheduled shower days and the resident's skin was not inspected," explained Certified Nursing Assistant 3.

The Director of Nursing called proper hygiene "imperative" for preventing pressure injury infections, noting that residents "have the right" to regular showers and that "good hygiene practices can help prevent or reduce the risk of pressure injury infection."

Meanwhile, another resident struggled with a more basic need. Resident 20 reported her hearing aids missing on January 28, telling the Social Services Director she felt irritated because others had to constantly repeat themselves when speaking with her.

During the March inspection, Resident 20 told investigators her hearing aids were still missing and "no one followed up" after she reported the problem. The Social Services Director admitted he "spoke with Resident 20 about her hearing aids but did not follow up" and "should have followed up with Resident 20's hearing aids and made an appointment for her to be seen."

The Administrator acknowledged that a resident not having hearing aids "can affect their dignity" and would benefit the resident so others "would not have to constantly repeat themselves when speaking to her."

Staffing shortages compounded the problems. Five residents with physician orders for range of motion exercises and mobility services failed to receive consistent treatment due to insufficient restorative nursing aide staff.

On March 9 and March 10, only one restorative aide was assigned to cover four nursing stations that normally require three aides. Staff told inspectors it was "not possible" for one aide to provide treatment to all residents requiring services.

Resident 40, a stroke survivor who used a wheelchair, expressed frustration about the inconsistent care. He told inspectors he received therapy exercises three times per week but was supposed to receive services five times per week. "He wanted RNA five times per week because he led a very active lifestyle and played sports prior to having a stroke," the report noted.

Restorative Nursing Aide 3 described the impact on residents: "Residents who did not receive RNA treatment had more pain and limited ROM when RNA 3 returned to providing RNA services."

The staffing problems extended beyond therapy services. In the subacute unit, insufficient licensed nursing staff resulted in delayed medication administration. Seven of 26 residents received their morning medications late on both March 12 and March 13.

Additional safety violations included a dialysis patient who lacked an emergency kit at her bedside and an IV patient whose catheter site remained unchanged for nine days without proper dating or rotation.

Resident 5, who required hemodialysis three times weekly, should have had an emergency dialysis kit containing gauze, a tourniquet, and bandages readily available. The Director of Nursing explained that without the kit, "there is the possibility resident could start bleeding from access site and die."

For Resident 22, whose IV catheter was placed at a hospital before admission, staff failed to label the insertion site with date and time or rotate it every 96 hours as required. The catheter site appeared to be leaking when inspectors observed it nine days after admission.

"There is a potential for phlebitis when IV sites are not rotated," the Director of Nursing explained.

The inspection revealed systemic failures in basic care protocols across multiple departments. Resident 154 remained lying on her left side for hours during the inspection, demonstrating the ongoing positioning problems that led to her injuries.

The facility's own policies required staff to assist hearing-impaired residents in maintaining effective communication and help residents who have lost hearing devices obtain replacement services. Similarly, their wound prevention policy called for certified nursing assistants to complete body checks on shower days and report findings to charge nurses.

But implementation fell far short of policy requirements. The Quality Assurance Nurse acknowledged that residents receiving restorative services "had the potential to develop contractures if RNA services were not provided."

Treatment Nurse 1 summed up the preventable nature of Resident 154's injuries: the pressure ulcers on her foot and buttock developed because she wasn't turned every two hours and protective boots weren't applied upon admission as they should have been.

For Resident 20, the solution was equally straightforward - someone simply needed to follow up on her request for hearing aids, as the facility's own accommodation policy required.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Vermont Healthcare Center from 2025-03-14 including all violations, facility responses, and corrective action plans.

Additional Resources

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