VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bickford of Chesterfield
11200 W. Huguenot Road
Midlothian, VA 23113
(540) 898-1205

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: Sept. 11, 2019 , Sept. 13, 2019 , Sept. 27, 2019 , Oct. 18, 2019 , Nov. 6, 2019 and Nov. 21, 2019

Complaint Related: No

Comments:

Responding to a 07/09/2019 facility self-reported resident incident regarding resident care, services and supervision; the inspector initiated an onsite inspection into the matter on 09/11/2019. Follow up interviews and on-site inspections to include the review of facility records and interviews with facility continued on 09/13, 27, 2019; 10/18/2019 and 11/06, 21/ 2019. The monitoring inspection identified multiple facility staff that was responsible for providing daily personal care services to the resident identified in the facility?s self-reported resident incident. The inspection also identified direct care staffs that are no longer employed at the facility; therefore these persons were not interviewed regarding this matter. The noncompliance revealed during this follow up monitoring inspection is contained within this report. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the Inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Please contact me at (804) 662-9774 or by e-mail at Angela.r.reaves@dss.virginia.gov. if you have any questions.

Violations:

Standard #:	22VAC40-73-40-A
Description:	Based on the review of facility records and facility staff interviews conducted on 09/11, 13, 27/2019; 10/01/2019 and 11/06, 20/2019 the licensee failed to ensure compliance with all regulations for licensed assisted living facilities and with the facility's own policies and procedures. Evidence: Resident #1-Documented date of admission: 03/18/2018; documented date of discharge: 06/29/2019. The review of facility records revealed that resident #1 lived on the facility?s Mary B?s; safe and secure unit. (1)-The facility?s PP-20700-Communication Policy (VA) - ?Revised: 10-2016? that was submitted for the inspector?s review on 11/06/2019 notes the following on Page 1 of 1-Procedure #2: ?At the end of each shift, Bickford Family Members shall document pertinent resident information, from their shift, in the Communication Book. The facility?s MB?s Daily Shift Report (end of shift report) that facility staff identified as the Communication Book in part notes: ?Change in Condition and Skin Problems?. The facility Administrator clarified that change in condition indicates guidance for assigned facility direct care staff members to document at the end of their shifts, pertinent information regarding the resident?s personal well-being. ' 08/29/2019 the department received an on-line complaint against the facility, alleging in part that on 06/29/2019 during the 3-11 shift resident #1 was transported to a local hospital for emergency medical intervention. ' 10/28/2019 via an email: Documentation pertaining to the 06/29/2019 complaint regarding resident #1 that was received at the department in part notes: ?His right foot was noticed to be significantly more swollen than usual and noted to also be cause for some kind of infection.? ' 11/19/2019 via Federal Express postal service: Documents received at the department also pertaining to the resident?s 06/29/2019 incident in part notes on page 150 under the heading ED Provider Notes by (doctor identified) ?Pt Presents to the ER with a fever and confusion. Pt. Found to have an ulcer and cellulitis of his foot. Pt. With some confusion and mental status changes. Pt. To be evaluated for admission by the hospital.? ' On the facility?s 06/29/2019 MB?s Shift Report charting for the 3-11 and 11-7 shifts; facility medication aide supervisors simply noted ?N/C?. The resident was transported to a local hospital during the 3-11 shift and was subsequently admitted. During interviews the facility Administrator clarified that ?N/C? indicates no change in the resident?s condition. During interviews the resident?s POA stated that facility medication aide; direct care staff #10 provided her assistance with redressing the resident for transportation for emergency medical intervention. The POA alleges that facility staff #10 also observed the residents toe and that staff #10 was shocked and stated ?I?d never seen that before?. Based on the review of submitted facility records and interviews conducted the Licensee failed to provide proper supervision over the affairs of the facility to ensure that facility staff maintained pertinent daily resident information per facility policy . Upon request to review the facility?s entire month of June 2019 MB?s Shift Reports (Communication Book); Completed Task Sheets and the facility?s Progress Notes that facility policy requires staff to maintain regarding resident #1; facility staff submitted the documents but the documents were either left blank with no entry, not dated or signed, not completely filled out or not documented with factual accounting of the resident?s incident(s). The facility Administrator and staff #9 both stated that they could not locate all of the requested documents.
Plan of Correction:	FACILITY RESPONSE- "The following measures will be taken to ensure that the violation does not reoccur: 1. All Staff were re-educated on the shift report documentation on 8/22/2019 and 10/15/2019. Another in-service training on documentation and proper ways to write reports have been scheduled for 03/17/2020 2. Nurse Coordinators will conduct routine shift report audits, 3 reports per week for 90 days. Persons responsible to implement and monitor corrective measure to ensure compliance: Director. Nurse Coordinator"
Standard #:	22VAC40-73-70-A
Description:	The facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. 07/09/2019 ten (10) days after the 06/29/2019 incident: The facility Administrator submitted an email to the department informing in part that ?On 6/29/19, one of the residents on our memory care unit was sent to the ER because he was agitated according to the staff on duty. According to his wife, when he go to the hospital, a staph infection was found on his big toe?. The Administrator?s email further stated ?I started investigating immediately I was informed that he was sent to the hospital.?
Plan of Correction:	FACILITY RESPONSE- "The following measures will be taken to ensure that the violation does not reoccur: a) Facility Director will report to the regional licensing office any major event that negatively affect residents within 24 hours via emails or phone Persons responsible to implement and monitor corrective measure to ensure compliance Director or designee"
Standard #:	22VAC40-73-70-D
Description:	Based on the review of facility records and facility staff interviews conducted the facility failed to submit to the regional licensing office amendments to the written incident report when circumstances require, such as when substantial additional actions are taken, when significant new information becomes available, or there is resolution of the incident after submission of the report. Evidence: Resident #1-Documented date of admission: 03/18/2018; documented date of discharge: 06/29/2019. On 09/11/2019 the inspector was on site at the facility and made facility staff aware of the complaint made against the facility regarding resident #1. The facility Administrator stated during interviews conducted on 09/11/2019 that facility staff #10 called her on 06/29/2019 and reported that the resident was sent out because of agitation. On 09/12/2019 the inspector forwarded an email to the facility Administrator that in part stated: ?Based on the discussions we had on yesterday and the lack of facility documentation does not align with what you?re reporting. Going forward, you could perhaps ask staff to submit documentation to you to verify their accounts of what happened. The inspector also stated in the 09/12/2019 email to the facility Administrator ?You must follow 22VAC 40-70 in its entirety when submitting incident reports. This continues to be an ongoing request.? As of 11/21/2019, the facility has not submitted an updated incident report regarding the resident?s 06/29/2019 incident to the department.
Plan of Correction:	FACILITY RESPONSE-"The following measures will be taken to ensure that the violation does not reoccur: 3. The Director sent in the amendments to the report om 1/27/2020 Persons responsible to implement and monitor corrective measure to ensure compliance. Director or Designee"
Standard #:	22VAC40-73-460-A
Description:	FACILITY RESPONSE- "(a) Staff have been instructed to always pay attention to changes in residents? physical appearance when assisting with bathing and dressing. In-Service was conducted on 8/22/2019 and 10/15/2019 to train staff on how to document these changes. (b) The Director will go through the staff tasks sheets and notify the nurse coordinators of any documentation pointing to a change in the physical appearance of any resident. (c) For all the residents in MB?s (Memory Care Unit): 1. 100% skin audit to be completed 2. Residents that are at risk for skin breakdown or infection will be identified (i.e., diabetes, malnutrition/weight loss/wight gain/Immobility/ falls risk, history of skin breakdown or infection, etc.,) 3. Residents at risk will be identified on their service plans, and skin care observation and reporting on tasks sheets will be required. 4. The director will audit 100% of the task sheets to ensure any skin needs are identified and communicated to the ACC 5. If it is identified there is any skin related issues these will also be verbally reported by the staff member, to the ACC/Director who will seek treatment orders, if indicated 6. The ACC will assess the skin and utilize the Skin Integrity audit and monitor/treat the area weekly until healed/resolved 7. Re- training and education occurred on 8/22/2019 and 10/15/2019. Another training is due on 03/17/2020. 8. The ACC will conduct random observation of Staff performing showers and skin checks on three residents per quarter x 2 quarters ? to demonstrate staff are following procedures and communicating appropriately 9. Every 90 days during nurse review and re- assessment process ? the ACC will identify any new risk factors that may lead to potential skin breakdown or infection and ensure these are noted on the service plan. Persons responsible to implement and monitor corrective measure to ensure compliance: The nurse coordinators. Director"
Plan of Correction:	FACILITY RESPONSE- "The following measures will be taken to ensure that the violation does not reoccur: (a) Staff have been instructed to always pay attention to changes in residents? physical appearance when assisting with bathing and dressing. In-Service was conducted on 8/22/2019 and 10/15/2019 to train staff on how to document these changes. (b) The Director will go through the staff tasks sheets and notify the nurse coordinators of any documentation pointing to a change in the physical appearance of any resident. (c) For all the residents in MB?s (Memory Care Unit): 1. 100% skin audit to be completed 2. Residents that are at risk for skin breakdown or infection will be identified (i.e., diabetes, malnutrition/weight loss/wight gain/Immobility/ falls risk, history of skin breakdown or infection, etc.,) 3. Residents at risk will be identified on their service plans, and skin care observation and reporting on tasks sheets will be required. 4. The director will audit 100% of the task sheets to ensure any skin needs are identified and communicated to the ACC 5. If it is identified there is any skin related issues these will also be verbally reported by the staff member, to the ACC/Director who will seek treatment orders, if indicated 6. The ACC will assess the skin and utilize the Skin Integrity audit and monitor/treat the area weekly until healed/resolved 7. Re- training and education occurred on 8/22/2019 and 10/15/2019. Another training is due on 03/17/2020. 8. The ACC will conduct random observation of Staff performing showers and skin checks on three residents per quarter x 2 quarters ? to demonstrate staff are following procedures and communicating appropriately 9. Every 90 days during nurse review and re- assessment process ? the ACC will identify any new risk factors that may lead to potential skin breakdown or infection and ensure these are noted on the service plan Persons responsible to implement and monitor corrective measure to ensure compliance:The nurse coordinators. Director"
Standard #:	22VAC40-73-460-A
Description:	Based on the review of facility records and facility staff interviews conducted on 09/11, 13, 27/2019 and 10/01/2019 and 11/06, 20/2019 the facility failed to assume general responsibility for the health, safety, and well-being of the resident. Evidence: Resident #1-Documented date of admission: 03/18/2018; documented date of discharge: 06/29/2019. On 08/29/2019 the department received a complaint against the facility, alleging in part ?On June 2019 I was called to the facility due to a suspected UTI. The med tech there could not give me a temperature reading, due to the lack of a reliable thermometer.? After the decision to transport for emergency medical intervention-the complaint further notes in part referring to resident #1; ?I then proceeded to redress him as his clothes were dirty and when I took off his socks I was presented with his right big toe which was infected and weeping. No one seemed to know anything about it, advising me that they had not seen it?. The complaint further notes in part referring to resident #1; ?He was in the hospital 2 weeks, had 3 operations, one being the amputation of his big toe and then 20 days in a skilled nursing facility.? During interviews the POA identified facility staff #10 as the caller that contacted her via a telephone call sometime around 4:30p.m on 06/29/2019. ' Facility staff assessed the resident on 06/10/2019 as needing mechanical & human help (physical assistance) with bathing, supervision with dressing and that the resident is disoriented in some spheres all of the time. ' The facility?s 2018 Mary B?s Shower Schedule-?Updated: June 15? that was submitted for the inspector?s review noted that Thursdays and Sundays during the 3-11 shifts (June 02, 06, 09, 13, 16, 20, 23, and 27/2019) were the resident?s scheduled shower days. ' On 11/19/2019 via the U.S. Postal Service, the department received documents regarding the resident?s 06/29/2019 emergency medical intervention. The documents notes in part on page 147: (resident identified) ?was admitted with 3 days of progressive AMS in the presence of obvious R great toe cellulitis. He was noted to be sceptic upon arrival and toe had a clear sinus tract draining purulent fluid.? Page 22 of the documents under the heading Assessment and Plan further notes in part: ?Of note, I agree with (doctor identified) that this ulcer had to have gone unnoticed for some time given the well formed sinus tract and degree of bony infiltration.? The documents also confirmed that the resident had a surgery to amputate his big right toe. Facility records revealed and facility staff interviewed noted staff?s acknowledgement that they all provided personal assistance and care to the resident based on his assessed needs but denied ever seeing any concerns regarding the resident?s foot. The facility?s Administrator and the Director of Resident Services also stated that they were not made aware of and have no knowledge of any concerns regarding the resident?s foot. The facility?s PP-20700-Communication Policy (VA) - ?Revised: 10-2016? that was submitted for the inspector?s review on 11/06/2019 also states: ?It is the responsibility of all Bickford Family Members to remain current on changes in resident needs.?
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-460-E
Description:	Based on the review of facility records and facility staff interviews conducted on 09/11, 13, 27/2019 and 10/01/2019 and 11/06, 20/2019 the facility failed to regularly observe, assess and document any notable changes in a resident's condition; including illness and injury, and any corresponding action taken in the resident's record and provide appropriate assistance when observation reveals unmet needs. Page 1 of 1 Procedure #3 of the facility?s PP-20700-Communication Policy (VA) - ?Revised: 10-2016? that was submitted for the inspector?s review on 11/06/2019 in part states: ?Completed Task Sheets, including notes, will be submitted to the Director at the end of each shift.? Facility staff clarified that the Director refers to the facility Administrator. Procedure #4 states ?The Director will review complete Task Sheets daily and follow up on issues. Task Sheets are to be for 2 years and then discarded if not needed for documentation.? ' Facility staff documented on a facility?s Progress Notes document dated 04/18/2019- 6:45A.M: ?Writer found red area on big toe when doing AM care. Resident did not c/o pain. Slippers were put on instead of shoes for comfort.? ' Facility staff also submitted for the inspector?s review two different MB?s Shift Reports that were not dated. On one document noting for the 11-7 shift: ?noticed that resident complained of shoes being small N/C? and the second MB?s Shift Report also not dated but noted by facility staff: ?Dressed-R toe has red area and swollen.? The facility did not submit upon the inspector?s request documentation of any follow up regarding these two entries. ' During interviews the facility Administrator stated that facility staff #10 informed her on 06/29/2019 that the resident was transported for emergency medical intervention because the resident was agitated but did not mention the condition of the resident?s foot. The facility Administrator further stated that facility staff #9 showed her a picture of the resident?s foot as it appeared on 06/29/2019. The facility Administrator stated during interviews that since staff #10 reported that the resident was sent out due to agitation; she saw no reason to follow up with staff #10 regarding the condition of the resident?s foot. The facility staff that were responsible for the resident?s daily personal care and the supervision of those staff allowed resident #1 to remain in care and did not provide for the inspector?s review documented evidence per facility policy that the facility conducted follow up assessments to determine whether there was a need for any medical intervention regarding the resident?s right toe and the resident?s shoes being too tight.
Plan of Correction:	FACILITY RESPONSE- "The facility shall regularly observe each resident for changes in physical, mental, emotional, and social functioning. Evidence: Based on review of facility?s records and facility staff interviews, the facility failed to regularly observe, assess, and document any notable changes in a resident?s condition. Including illness and injury, and any other corresponding action taken in the resident?s record and provide appropriate assistance when observation reveals unmet needs. The following measures will be taken to ensure that the violation does not reoccur: 1. A nursing assessment will be conducted on all new residents prior to move in, at 30 days and a 90-day nurse review after move in. Any skin related issues/ needs will be treated and monitored on the weekly Skin Audit tool 2. Staff have been re-trained by in-service on 11/07/19 to pay more attention to changes in residents? conditions. This will include paying close attention to physical, emotional, and mental changes. Each staff will document on their tasks sheets for the shift worked observed changes in residents? conditions. They will also inform the designated staff person in charge when the Director is not on site. Another In -service training on Residents ADLs, Hygiene and grooming has been scheduled for 07/21/2020. 3. In- Service was conducted on 8/22/2019 to re-train staff on the expectations for documentation on the shift report. Staff will fill out the report completely with accurate dates. Persons responsible to implement and monitor corrective measure to ensure compliance: The nurse coordinators. Director"