VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Runk and Pratt at Liberty Ridge
30 Monica Blvd.
Lynchburg, VA 24502
(434) 237-2268

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: Feb. 12, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 63.2 Protection of adults and reporting. 22VAC40-80 COMPLAINT INVESTIGATION.

Comments:

The LI for Runk and Pratt at Liberty Ridge, in conjunction with another LI, conducted an unannounced complaint inspection in response to a complaint that was received by the licensing office on 01/24/2020. The LIs reviewed three resident records and conducted interviews with staff relating to allegations that residents are being admitted to the facility that are not appropriate and cognitively impaired residents are eloping from the facility. The complaint investigation was also conducted in regards to a resident elopement that occurred on 01/22/2020. The information gathered during the investigation does not support the allegation of inappropriate admissions, but does support the allegation of resident elopement. Based on the preponderance of evidence, the complaint is determined to be valid. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to your licensing 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 noncompliance 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). If you have any questions, contact your licensing inspector at (540) 589-5216.

Violations:

Standard #:	22VAC40-73-70-C
Complaint related:	No
Description:	Based on review, the facility failed to submit a complete written report of an incident that negatively affected or threatened the life, health, safety or welfare of a resident to the regional licensing office within seven days from the date of the incident. EVIDENCE: 1. On 01/22/2020, staff 1 sent an email that resident 1 ?went off ground but was safely returned to the facility. He was ok with no injuries but we sent him to the Er to be for evaluation. Family was notified and they came in and they were very pleasant. He will be moved to our Locked unit POL upon return from the hospital.? The email did not include the following required information about the incident: date and time of the incident, description of the incident, the circumstances under which it happened, and when applicable, extent of injury or damage, location of the incident, name of staff person in charge at the time of the incident and names, telephone numbers, and addresses of witnesses to the incident, if any.
Plan of Correction:	Training was provided at the facility on what information needs to be submitted to the Regional Licensing office when submitting a written report of an incident that negatively affects or threatens the life, health, safety or welfare of a resident.
Standard #:	22VAC40-73-440-D
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure that the uniform assessment instrument (UAI) was completed as required. EVIDENCE: 1. The UAI dated 01/03/2020 for resident 2 states that the resident needs no assistance with bathing. The individualized service plan (ISP) dated 01/04/2020 for resident 2 states that the resident needs mechanical assistance only with bathing; will use assistive device (grab bars/shower bench) during showers, without staff assistance. Interview with staff 2 revealed that resident 2 does need mechanical assistance with bathing. 2. The UAI dated 01/28/2020 for resident 3 states that the resident does not need assistance with bowel continence, needs mechanical help with mobility and does not need help with independent activities of daily living (IADLs); meal prep, housekeeping, laundry or money management. The ISP for resident 3 states that resident has bowel incontinence less than weekly and that direct care staff provides services for this daily at the facility. The ISP also states that resident 3 needs physical assistance for mobility; physically assist when in/out of the facility for safety and that housekeeping, direct care staff and dietary provide housekeeping: sweep/mop/vacuum bedroom & bathroom floors, empty trash, dust and clean bathroom fixtures; laundry: clothing to be washed, laundered delivered and put away (per resident/family request); meal prep: dietary to prepare three well balanced meals daily including at least two snacks in between meals. Interview with staff 2 revealed that resident 3 does need assistance with bowel incontinence, mobility and with IADLs.
Plan of Correction:	The conflict was resolved in both the ISP and UAI. It is reflected in both ISP and UAI that resident needs mechanical assistance with bathing. The conflict resolved in both ISP and UAI reflecting that resident 3 does need assistance with bowel incontinence, mobility, and with IADL?s. DON provided training to Unit Managers on this and will continue to monitor.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on review of resident record, the facility failed to ensure that the comprehensive individualized service plan included a description of identified needs and date identified based upon the uniform assessment instrument (UAI). EVIDENCE: 1. The UAI dated 01/03/2020 for resident 2 states that resident needs medication administration/monitoring assistance by a lay person. The ISP for resident 2 states that resident needs medication management with assistance, medication will be given per M.D. order and observed for side effects and that resident will safely administer meds without assistance per MD order. Interview with staff 2 revealed that resident 2 does need medications to be administered by a lay person. 2. The record for resident 2 contained a physician?s order dated 02/05/2020 that resident 2 is to have meal reminders ? ?remind resident of all meal times?. This was not documented on the ISP for resident 2.
Plan of Correction:	The ?without? was a typo and it was corrected showing that resident needs medication management by a lay person. Meal reminders for resident 2 was care planned.
Standard #:	22VAC40-73-460-D
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises. EVIDENCE: 1. The individualized service plan (ISP) dated 12/19/2019 for resident 1 states that resident will have wanderguard elopement precautions, that direct care staff/RMA/Nurse will check placement and battery of bracelet every shift daily in room at facility and that resident will be free from leaving facility unattended. 2. The ISP dated 12/19/2019 for resident 1 states that resident will be on safety checks (Q2 hour checks) due to resident?s inability to use call bell due to cognitive or physical impairment; direct care staff will monitor resident every two hours daily at the facility and that resident will remain safe and all needs will be met. The ?Q2 HR CHECK OFF SHEET? was initialed by staff on 01/22/2020 at 9:00 AM, 11:00 AM, and 1:00 PM. 3. Interview with staff 1 revealed that resident 1 left the facility out of a side door. Staff 1 confirmed resident was wearing wanderguard at time he exited the building and that resident 1 was moving fast per video footage. Staff 1 stated that resident 1 left the facility sometime between 9:00AM ? 9:30AM. 4. The police report from the Campbell County Sheriff?s office shows staff 4 made a missing person report around 9:45AM on 01/22/2020. Around 2:00PM a liberty student (Liberty University) advised the sheriff?s office that they were out with resident 1 at Camp Hydaway; approximately 2.8 miles from the facility. Liberty University police transported resident 1 to their department and then Campbell County Sheriff?s office investigators picked up resident 1 to transport resident back to the facility where medical transport was waiting to take resident 1 to Lynchburg General Hospital (LGH). Resident 1 was admitted to LGH on 01/22/2020 for ?wandering outside of facility for extended period of time? and was discharged from the hospital on 01/24/2020. 5. According to accuweather.com, the high temperature for 01/22/2020 was 44 degrees Fahrenheit and the low temperature was 17 degrees Fahrenheit.
Plan of Correction:	All residents with wander guards were moved to our locked/memory care units. This Runk and Pratt Facility no longer accepts wander guards. Staff were educated on doing two-hour checks, and the importance of doing them in real time. DON is following up on this.