VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Wybe & Marietje Kroontje Health Care Center
1000 Litton Lane
Blacksburg, VA 24060
(540) 953-3200

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: Nov. 30, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 63.2 Facilities and Programs..

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 11/30/2020 and concluded on 12/04/2020. A self-reported incident was received by the department regarding allegations in the areas of personnel, resident care, and facilities and programs. 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.

Violations:

Standard #:	22VAC40-73-190-F
Description:	Based on information received as a facility self-reported incident, the facility failed to ensure the staff members in charge is prepared to carry out his duties and responsibilities. EVIDENCE: 1. According to documentation provided by the facility. Staff # 2 was in charge on day shift in the secure unit and staff # 4 was in charge on the secure unit during the evening shift. Both staff # 2 and staff # 4 shared the person in charge responsibilities and providing evening meals to residents. 2. Staff # 4 was listed as being in charge on the evening of 11/29/2020 when 12 residents in the memory care unit did not receive their evening meal. When interviewed staff # 4 stated resident's are normally eating and finishing up dinner when she comes on shift at 6 pm. She stated on this date she was not aware that residents did not receive their evening meal until around 7 pm when she was notified by staff # 3 the meals were still on the warming cart. Staff # 4 stated she was concerned about the resident's not receiving their meals but by the time it was brought to her attention the resident's were sleeping and she did not wake them to eat. Staff # 4 stated some of the meals were refrigerated in case the residents awoke hungry.
Plan of Correction:	Please see Intensive Plan of Correction.
Standard #:	22VAC40-73-450-H
Description:	Based on documentation review, the facility failed to ensure the care and services specified in the individual service plan (ISP) was provided for 12 residents in care. EVIDENCE: 1. The ISP's for resident # 1 dated 05/12/2020, resident # 2 dated 06/01/2020 dated 09/01/2020, resident # 4 dated 09/01/2020, resident # 6 dated 07/24/2020, resident # 8 dated 12/02/2020, resident # 9 dated 03/01/2020, resident # 10 dated 04/01/2020, resident # 11 dated 06/25/2020 and resident # 12 dated 01/01/2020 states they will be assisted with eating three meals per day. 2. The ISP for resident # 3 dated 05/01/2020 states she will be assisted with eating three meals per day and is assisted by staff with feeding at times. 3. The ISP for resident # 5 dated 05/01/2020 states he will be assisted with eating three meals per day and staff assists with feeding at times. 4.The ISP for resident # 7 dated 02/01/2020 states she will be assisted with eating three meals per day and this includes being spoon fed at times. 5. The ISP for resident # 8 dated 12/01/2020 states she will be assisted with eating three meals per day and this includes being spoon fed at times. 6.. The resident's listed above did not receive their evening meal on 11/29/2020 therefore the services to assist with meals were not met on this date.
Plan of Correction:	Please see Intensive Plan of Correction.
Standard #:	22VAC40-73-460-D
Description:	Based on documentation review and interviews with staff, the facility failed to provide supervision of resident schedules, care and activities, including attention to specialized needs such as meal times and assistance with meals. EVIDENCE: 1. According to documentation submitted by the facility including the evening meal report for 11/29/2020 residents # 1,2, 3, 4, 5, 6, 7, 8, 9, 10, 11, &12 were not served their evening meal on this date. 2. When staff #1 & #2 were asked why they did not serve resident's their evening meal on this particular day they both stated" they were busy helping residents' get into bed because night shift is short staffed". Both staff # 1 & 2 stated they had gotten most of the residents into bed but they were not aware that the dining staff had delivered the trays to the memory care unit. According to the staff schedule there were two Certified Nursing Assistants and one nurse on staff for the evening of 11/29/2020 on the memory care unit to care for a total of 16 residents. 3. Staff # 1 and # 2 stated they reported to staff # 3 that meals had not been served to residents at the end of their shift and they assumed staff # 3 was going to take care of serving dinner to residents. 4. Staff # 1 and # 2 made the decision on their own to assist residents to bed around 4:30 or 5:00 pm to assist night shift without offering or providing an evening meal. Staff # 1 & #2 stated they normally distribute meals before the time their shift ends but on this particular evening aside from not being told the meals had arrived to the memory care unit they both had personal obligations that needed to be taken care of and they needed to be able to leave as soon as their shifts ended. 5. Staff # 4 who was in charge at the time of the incident stated staff # 3 reported to her at approximately 7 pm there were trays for residents still on the warming cart and she was not sure why. Staff # 4 stated she was very concerned that the resident's did not receive their meals and she felt there was no reason why they were not served their dinner. Staff # 4 stated resident's should have been finishing up their evening meals by 6 pm. Instead they were sleeping at this time. 6. According to documentation provided by the facility none of the four staff members on duty at the time evening meals were to be distributed took responsibility for the supervision and attention to specialized care needs to ensure each resident in memory care were given their evening meal and assisted with feeding on 11/29/2020.
Plan of Correction:	Please see Intensive Plan of Correction.
Standard #:	22VAC40-73-590-A
Description:	Based on information received as a facility self-reported incident, the facility failed to ensure at least three well-balanced meals, served at regular intervals, would be provided daily to each resident. EVIDENCE: 1. According to documentation provided by the facility the evening meal is served between 5:30 and 6:00 pm. On the evening of 11/29/2020 twelve residents on the memory care unit were not provided their evening meal. 2. According to staff members #1 and # 2 on duty in the memory care unit the dining staff did not provide notification the evening meal had been delivered to the unit. 3. According to documentation provided by the facility the meals are delivered within the same time frame each day. The evening meal time overlaps two shifts and staff # 1 and # 2 did not take the responsibility to distribute evening meals to 12 residents in care
Plan of Correction:	Please see Intensive Plan of Correction.
Standard #:	22VAC40-73-600-A
Description:	Based on information provided to the licensing department as part of a facility self-reported incident, the facility failed to ensure the time interval between the evening meal and the scheduled breakfast the following morning shall not exceed 15 hours. EVIDENCE: 1. According to documentation submitted by the facility including the evening meal report for 11/29/2020 residents # 1,2, 3, 4, 5, 6, 7, 8, 9, 10, 11, &12 were not served their evening meal on this date. 2. The documentation stated the 12 residents were served lunch on 11/29/2020 at approximately 12:00 pm. They were not served their evening meal. The 12 residents were served breakfast the following morning 11/30/2020 at approximately 7:30 am which was 19 and a half hours exceeding the allowed 15 hours.
Plan of Correction:	Please see Intensive Plan of Correction.
Standard #:	22VAC40-73-680-D
Description:	Based on review of physicians orders and medication administration records, (MARs), the facility failed to ensure medications shall be administered in accordance with physicians or other prescriber's instructions. EVIDENCE: 1. Resident # 6 is prescribed Quercetin/Bromelain 800 mg/165 mg take two capsules by mouth twice daily with breakfast and dinner for 14 days as a supplement. It is documented on the resident's MAR he was given his evening dose of this medication on 11/29/2020 at 5 pm. According to the meal report dated 11/2/2020 this resident did not receive his evening meal with his medication on this date. 2. Resident # 10 is prescribed Novolog 100 U/ml to inject 6 units three times daily with meals for glucose greater than 200. This medication is to be inject 10-15 minutes prior to mealtimes and bedtime snack. It is documented on this resident's MAR he received his dose of insulin on the evening of 11/29/2020 at 5:30 pm He is prescribed Carbid/Levo tablets 25/250mg take one tablet by mouth three times daily before meals for Parkinson's disease. He is prescribed Tamsulosin cap 0.4mg take one capsule by mouth one time daily in the evening after dinner for benign prostatic hypertrophy . According to the meal report this resident was not served his evening meal after his medication was administered. 3. Resident # 12 is prescribed Tamsulosin cap 0.4mg take one capsule by mouth one time daily in the evening after dinner for benign prostatic hypertrophy . According to the meal report this resident was not served his evening meal after his medication was administered.
Plan of Correction:	Please see Intensive Plan of Correction.
Standard #:	63.2-1808-A-11
Description:	Based on information received by the department of licensing as part of a facility self-reported incident and documentation review, the facility failed to ensure each resident with courtesy, respect, and consideration as a person of worth, sensitivity, and dignity. 1. According to documentation submitted by the facility and interviews with staff twelve residents were not served their evening meal on 11/29/2020. 2. The evening meal overlaps two shifts and the day shift and oncoming evening shift share the responsibility to serve residents their dinner. 3. On the evening of 11/29/2020 staff # 1 and 2 assisted resident getting into bed between 4:30 and 5:00 pm instead of offering their evening meal during this time which is standard procedure. According to interviews with staff it was reported to staff # 3 & staff # 5 who came on at 6:00 pm that resident's needed to have their meals distributed. No one took responsibility to ensure the evening meals were offered to 12 residents and they ended up not being served dinner. 4. According to training documentation all staff on duty during this incident have completed training in respecting resident rights. 5. All residents involved in this incident are placed on the safe and secure unit making them an extremely vulnerable population to abuse and neglect.
Plan of Correction:	Please see Intensive Plan of Correction.