VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Karolwood Gardens at Norfolk
6403 Granby Street
Norfolk, VA 23505
(757) 451-2400

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Jan. 31, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 BUILDING AND GROUNDS

Comments:

An unannounced complaint inspection was initiated on 01/31/2022 and concluded on 03/03/2022. A complaint was received by the department regarding allegations in the areas of staffing and supervision and resident care and related services. The licensing inspector conducted an on-site observation at the facility on 01/31/2022 and 02/14/2022. Records were reviewed along with staff interviews held. Any violations related or not to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-150-C
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure implement policies, procedures, and services established by the facility. Evidence: 1. Resident #1 fell on the early morning hours of 12/23/2021 and did not go to the emergency room until approximately 5 hours after the fall. There were only CNA staff in the facility from 11:00 pm to 7:00 am. 2. On 03/02/2022, Staff #1 stated if there are only CNAs on duty that ?the staff is instructed to call 911 if someone falls.? Staff #1 also stated ?staff learn that as part of the CPR/First Aid training.? 3. Staff #1 acknowledged on the early morning of 12/23/2021 this was not followed as Resident #1 fell and 911 was not called until a nurse arrived for their 7:00 am shift.
Plan of Correction:	Policies, procedures and services were established by the facility. A 100% audit was completed to ensure that appropriate policies, procedures and services were established per DSS regulations. An in-service will be completed by the Resident Care Coordinator/designee for staff to introduce them to the new policy and procedure manual. The Administrator/designee will complete an audit of incident reports and 24-hour report to ensure policy and procedures are being followed daily for 8 weeks. Additional audits may be completed as part of the quarterly healthcare oversight and findings will be reported administrator. Any identified variances will be investigated and corrected as appropriate.
Standard #:	22VAC40-73-930-D
Complaint related:	Yes
Description:	Based on observation and interview, the facility failed to ensure direct care staff make and document rounds no less often than every two hours for each resident with an inability to use the signaling device or at the facility?s planned frequency to monitor for emergencies or other unanticipated resident needs. Evidence: 1. Resident #1 admitted to the facility on 12/10/2021 into the safe, secure environment with a fall resulting in major injury on the early morning hours of 12/23/2021. While on-site on 01/31/2022, there was no documentation or evidence that the facility made rounds no less often than every two hours after Resident #1 went to bed on the evening of 12/22/2021 nor early morning hours of 12/23/2021. 2. Staff #2 acknowledged the facility does not document rounds no less often than every two hours for each resident with an inability to use the signaling device or at the facility?s planned frequency to monitor for emergencies or other unanticipated resident needs.
Plan of Correction:	On 1/31/2022 the facility immediately implemented 2-hour rounds. On 1/31/2022 the facility implemented a 2-hour round sheet for direct care staff in the safe, secure environment. An in-service will be completed by the Resident Care Coordinator/designee for staff to introduce them the 2-hour rounds sheet for direct care staff in the safe, secure environment. The Administrator/designee will complete an audit of the 2 hours rounds sheet to ensure the policy and procedures are being followed 3x a week for 8 weeks. Additional audits may be completed as part of the quarterly healthcare oversight and findings will be reported administrator. Any identified variances will be investigated and corrected as appropriate.