VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Linden House
1250 Branchlands Drive
Charlottesville, VA 22901
(434) 973-0311

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

Inspection Date: April 22, 2021

Complaint Related: Yes

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. An unannounced complaint investigation was initiated on 04/22/2021 by the licensing inspector. The Administrator was contacted by telephone to initiate the inspection. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed the facility's medication administration records, Uniform Assessment Instrument (UAI), ISPs, facility nurses notes and conducted interviews with facility staff and others. The evidence gathered during the investigation supported the determined non-compliance(s) with applicable standards or law. Violations were documented and are on the violation notice issued to the facility. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and returned it to me 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 please feel free to contact me at (804) 840-0253 or by e-mail at Angela.r.reaves@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based on the review of facility records and interview conducted the facility failed to implement a written plan that ensured that each resident's prescription medications and any over- the- counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: Resident #1 The residents Medication Administration Record (MAR) charting for April 2021 that was submitted for the inspector?s review revealed the following: ACIDOPHILUS CAP 500MM- 1 CAPSULE BY MOUTH TWO TIMES A DAY FOR 14 DAYS Facility staff documented on 04/30/2021 for the 8:00p.m administration ?not available?. CLINDAMYCIN CAP 150MG- 3 CAPSULES BY MOUTH EVERY SIX HOURS FOR 5 DAYS- 04/27/2021: Charting at 4:53p.m for the medication to be administered at 6:00p.m facility staff noted ?medication not available? 04/28/2021: Charting at 2:11a.m for the medication to be administered at 12:00a.m facility staff noted ?med not in cart will call Remedi? DICLOFENAC GEL 1 %; APPLY 4 GRAMS TO THE RIGHT KNEE TOPICALLY THREE TIMES A DAY FOR PAIN. Facility staff documented on 04/01, 09, 12, 14, 16/2021 that the medication was not available for administration to the resident. 1% of the topical cream Terbinafine to be administered topically to feet/between toes and to toenails two times a day for 4 weeks; Beginning 04/02, 03, 04, 05, 06, 07, and 08/2021: facility staff documented that the medication was not in cart or could not locate the medication for the 8:00 a.m. administration.
Plan of Correction:	FACILITY'S RESPONSE: "Resident #1 referenced in the complaint inspection was discharged from the facility 1 OCT 2021. The period of past non-compliance identified will be addressed by the Wellness Director and/or designee conducting an lnservice for appropriate clinical personnel to re-educate the staff on the DSS approved facility medication management plan with a specific focus on sections 7 and 9. The facility Wellness Director and/or designee will coordinate with Remedi Pharmacy representative to ensure all appropriate systems are in place and forms readily available to staff to ensure refills of medication are completed timely. After the initial audit the Wellness Director and/or designee will conduct sample audits once per month for 3 months, then once per quarter for 3 quarters to ensure continued compliance. "
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on the review of facility records and interview conducted the facility failed to ensure that medications were administered in accordance with the physician's or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Resident #1: The complainant alleges that on or about Monday April 12th the residents? physician ordered that a diuretic was to be discontinued but the facility continued to administer the medication. The resident?s physicians? order received at the facility on 04/12/2021 t 10:34 a.m.in part notes ?Hold Bumex until further notice STAT BMP Push po fluids to at least 2L/day?. The facility?s Medication Administration Record (MAR) charting for April 2021 that was submitted for the inspector?s review notes in part ?Bumetanide 2mg; 2 TABLETS (4 MG) BY MOUTH ONE TIME A DAY? On 04/13/2021 and 04/14/2021 at 8:00a.m two different facility staff administered 4mg of the medication Bumetanide to resident #1 after the discontinued order had been received at the facility.
Plan of Correction:	FACILITY'S RESPONSE: "Resident #1 referenced in the complaint inspection was discharged from the facility 1 OCT 2021. The period of past non-compliance was identified by facility personnel and reported to the Department of Social Services as substantiated on 4/29/2021. On 14 APR 2021 Bumex was pulled from the medication cart and staff were educated on the correct way to update an EMAR when a hold order is received. Also, a recommendation of having the attending physician fax the orders directly to the pharmacy was made. The facility Wellness Director and/or designee will conduct an all-clinical staff training to consist of Medication Administration competency and standards of practice for medication aides. The facility Wellness Director and/or designee will conduct a comprehensive audit of facility charts to review accuracy of medication administration compared to prescriber's instructions. After the initial audit the wellness Director will conduct sample audits once per month for 3 months, then once per quarter for 3 quarters to ensure continued compliance"