VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Meadow Glen of Leesburg
315 Dry Mill Road
Leesburg, VA 20175
(703) 737-6149

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: Oct. 12, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 10/12/20 and concluded on 11/17/20. A self-reported incident was received by the department regarding: Resident Care and Related Services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on interview, the facility failed to ensure that medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: The facility reported that Residents #1-8 did not receive their 8 PM medications on 10/10/20. The facility reported finding a glove, with medications inside, in the medication cart. Staff #1 was interviewed and she reported that she removed the pills, from the medication packages, and placed the pills in the medication cart. Staff #1 signed the medications, for Residents # 1-8, as being administered on the electronic medication administration record (eMAR) on 10/10/20 (8 PM administration). Staff #1 reported that she had assisted with other tasks, and that she forgot to administer the medications.
Plan of Correction:	The established licensed employee was responsible to administer medication to the community on 10/10/2020. On 10/12/2020 it was brought to the Resident Care Coordinator?s attention that a glove of pills was found in the medication cart. After investigating the RCC and ED were able to determine that 8 residents evening medications were in the glove. The medication administration record was obtained, and the employee who signed the medication as given for the 10/10/2020 and 10/11/2020 was asked to come in for an interview. The employee was questioned and terminated on 10/12/2020 as a result of the interview. The employee acknowledged she did not administer the medication but punched them from the pack and put them in a glove for disposal. The RCC had retraining with employees on job duties and outlets if an employee is overwhelmed, concerned or needs assistance at any time. The physician?s and families for all 8 residents were notified of the medication not being administered. The RCC and ED will speak with each licensed medication professional on how to deal with stressful situations and to assure that they know proper procedures and standards expected of the employee.