VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bellaire at Stone Port
1684 Port Hills Drive
Harrisonburg, VA 22801
(540) 246-0888

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: May 21, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Recommended conducting an in-service on a monthly basis regarding best practices in medication administration and ensuring the five rights of medication administration are being followed.

Comments:

A monitoring inspection was conducted on 5/21/19 from approximately 3:00 pm to 5:10 pm in response to incidents that occurred regarding medication administration and resident retainment. Based upon interviews and documentation, non-compliance was found in the area of medication administration. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. If you have any questions, contact your licensing inspector at (540) 430-9258.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based upon documentation and interviews, the facility failed to ensure two of two residents medications were administered in accordance with the physicians' orders. Evidence: 1) Resident A had a signed physician's order on file for one 0.5mg tablet of Clonazepam at 10:00 pm. 2) The narcotic count sheet indicated staff A administered Clonazepam at 9:35 pm on 5/14/19. The May 2019 medication administration record (MAR) indicated staff B administered Clonazepam at 10:00 pm on 5/14/19. 3) On 5/21/19, the LI interviewed staff A who stated she had marked the MAR and the narcotic log book on 5/14/19 and administered the Clonazepam to resident A. She stated she did not know why the MAR showed the Clonazepam as not being given. As a result, upon shift change staff B checked the MAR for medications due and Clonazepam was still showing as due so staff B administered the Clonazepam to resident A also. 4) Resident B had a signed physician's order dated 4/11/19 for 34 units Basaglar and a signed discontinued order on 4/11/19 for sliding scale Humalog. 5) On 6/13/19, the LI interviewed staff C who stated, "I was getting his meds ready and he was on Humalog for quite a while and it was discontinued but it hadn't been pulled out of the cart. I had prepared his medications and then someone yelled for me for assistance so I put the meds back in the top drawer of the cart. I came back to the cart and grabbed his medications from the cart and was talking to a resident at the same time - there were four people waiting for their medications. I went to the resident's room and drew up 34 units of Humalog and before I left the room I realized what I had done. I immediately notified the resident's doctor and my supervisor. I was rushing and didn't do checks again and just grabbed the wrong pen. I caught it fast and kept the blood sugar at a good level." 6) Incident reports were completed and on file and included the details of both incidents listed above. Staff completed witness statements stating the above which were also on file. The May MAR also indicated the Humalog was given instead of the Basaglar.
Plan of Correction:	1) All discontinued and expired medications were removed from medication cart. Proper medication pass policy and procedures were reviewed with all staff to include the five rights of medication administration. Proper documentation procedures were reviewed with staff. 2) All registered medication aides (RMAs) and licensed practical nurses (LPN) attended a four hour medication administration refresher class on 6/12/19. Staff A, B and C were assigned additional online courses regarding safe medication passes. Staff A and B will receive weekly medication pass audits for 90 days. Both will receive 30-day performance evaluations for 90 days. RMAs and LPNs will self audit medication carts weekly for discontinued or expired medications. 3) Director of health and wellness (DHW) will monitor for future compliance with weekly medication pass audits for 90 days and then twice monthly. Facility will continue quarterly medication cart audits with the consulting pharmacy.