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: Jan. 16, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Recommended all staff (housekeeping, maintenance, activities, direct care, etc) complete an in-service on the storage of medications. Also recommended that residents who self-administer their medications sign a statement that they will store their medications at all times in a locked box/container. Recommended a system be developed for staff to check the storage of the medications to ensure compliance and develop a policy for residents who continue to be non-compliant.

Comments:

An unannounced non-mandated inspection was conducted on 1/16/20 from 11:35 am to 6:05 pm. Medication administration observations were completed for four residents and three registered medication aides. The medication administration records and physicians' orders were reviewed for all medications. Storage of medications were also checked for nine of the residents who self-administered medications. Interviews were conducted with residents and staff. The areas of noncompliance were verbal orders and storage of self-administered medications. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation during this inspection.

Violations:

Standard #:	22VAC40-73-650-C
Description:	Based upon record reviews and interviews, the facility failed to ensure two of the four resident records reviewed had verbal orders signed within 14 days. Evidence: 1) Resident C had a verbal order dated 1/10/19 for Risamine Ointment and Lamotrigene; resident D had verbal orders dated 9/3/19 for Dermaseptin ointment (scheduled and as-needed); however, none of these orders were signed by the physician. 2) On 1/16/20, the licensing inspector (LI) interviewed the director of health and wellnes (DHW) and the administrator and both reviewed the files and stated they could not find the signed orders.
Plan of Correction:	1. Prescribing physician signed verbal orders for residents C and D on 1/31/2020. 2. All licensed nurses and registered medication aides will fax oral orders received to the prescribing provider requesting the physician or other prescriber to sign and re-fax within the 14-day period. A copy of all oral orders with fax confirmation to provider will be placed in a binder at each nurse's station. The DHW, dayshift licensed practical nurse (LPN) or designee will check the binder twice weekly to follow up on any oral orders that have not been signed. 4. Training with the licensed nurses and registered medication aides will be completed by 2/21/2020.
Standard #:	22VAC40-73-660-B
Description:	Based upon observations, the facility failed to ensure three of the nine residents who self-administered their medications stored them so they were inaccessible to other residents. Evidence: 1) On 1/16/20, the LI and DHW went to residents' rooms to check on the storage of self-administered medications. Residents G, L and M had medication storage boxes in their rooms; however, the medications were stored on tables and shelves rather than in the locked medication boxes and the medications were therefore accessible to their roommates. 2) On 1/16/20, the LI interviewed resident G who stated he had not stored his medications in the medication box that was provided to him.
Plan of Correction:	1. Residents G, L and M were instructed on day of inspection to keep their medications in the lock boxes that had been provided so that they were inaccessible to their roommates. 2. All staff, including housekeeping, maintenance, activities, nursing and direct care, will be trained on the proper storage of medications when residents are self-administering. 3. The DHW, dayshift LPN or designee will complete audits of resident rooms to verify that medications are stored properly. The audits will be conducted weekly for one month, bi-weekly for one month, then random monthly audits for six months. 4. Associates will be in-serviced on medication storage by 2/21/2020 and medication audits will commence on 2/4/2020.