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: Oct. 31, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

A renewal inspection was initiated on 10/31/2021 and concluded on 01/10/2022. The administrator was contacted by email to initiate the inspection. The administrator reported that the current census was 80. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed (4) resident records, (4) staff records, activities calendar, staff schedules, health care oversight reviews, medication administration records, menus, fire drills etc. submitted by the facility to ensure documentation was complete. On 11/15/2021 the inspector reviewed the noncompliance with the Assistant Administrator and Director of Nursing and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. On 01/10/2022 an onsite inspection of the physical plant was conducted as well as observation of medication administration pass was observed on the facility?s memory care unit and assisted living program. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. If you have any questions I can be reached at (804) 840-0253 or angela.r.reaves@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure 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 #2: The resident?s medication administration record charting for October 2021 notes 06/18/2021 as the start date of the medication Lorazepam; one-0.5mg tablet to be administered daily by mouth at bedtime. Beginning 10/1-24/2021 facility staff documented that the medication was not available and onsite; indicating that the medication was not administered to the resident per physicians? order.
Plan of Correction:	FACILITY'S RESPONSE: "Resident #2 was evaluated by her PCP on September 8, 2021. In the written plan of care, the PCP noted that Lorazepam prescription would not be refilled. This is why the medication was not administered October 1, 2021 through October 21, 2021. A pharmacy oversight was completed 10/6/21, for resident #2 and no medication irregularities were noted. On October 25, 2021, The Director of Wellness received clarification from the PCP that the medication was to be discontinued. The pharmacy was sent a discontinued ordered on October 25, 2021. The Director of Wellness or designee will review orders from PCPs, and verify that the pharmacy has been notified via fax of discontinued orders, and medications are discontinued from the electronic medication record within 24 hours. The Director of Wellness or designee will verify discontinued orders have been processed timely and correctly for 4 weeks beginning January 17, 2022 through February 14, 2022."
Standard #:	22VAC40-73-680-K
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that the use of PRN medications is prohibited, unless: The resident is capable of determining when the medication is needed; when the facility has obtained from the resident's physician or other prescriber a detailed medication order that included symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period, and directions as to what to do if the symptoms persist. Evidence: Resident #4 The resident?s physician?s orders dated 10/21/2021 that was submitted for the inspector?s review noted that the resident is prescribed two- 325 mg tablets of the medication Acetaminophen is to be administered every four hours as needed for pain and/or fever. Two different facility registered medication aides documented that the medication was administered to the resident #4 on 09/07/2021; 10/22, 24, 25/2021 without authorization from the prescribing physician. The facility did not submit upon request facility nurses/progress notes or any other facility documentation that the facility?s registered medication aides reported the observed behaviors to the resident?s physician and received written guidance from the residents? physician prior to administering the medication Acetaminophen to the resident.
Plan of Correction:	FACILITY'S RESPONSE: "The LPN manager faxed the PCP for resident #4 on January 14, 2022 for a detailed order for administering Acetaminophen; to include directions if symptoms persist. The LPN manager and Director of Wellness will re-educate all registered medication aides on the use of PRN medications, and steps to be taken if the resident is not capable of determining when the PRN medication is needed. The Director of Wellness or designee will monitor PRN medications administered by registered medication aides to verify that proper documentation is included to support the administration. Re-education will be provided to all registered medication aides by February 4, 2022."