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Spring Arbor of Williamsburg
935 Capitol Landing Road
Williamsburg, VA 23185
(757) 565-3583

Current Inspector: Kimberly Rodriguez (757) 586-4004

Inspection Date: Aug. 23, 2018

Complaint Related: No

Areas Reviewed:

An unannounced monitoring inspection was conducted on 8-23-18 (arrival 1:00pm /departure 4:00 pm) regarding a "medication error report received by the department on 7-29-18. Staff interviews and resident record was reviewed. An exit interview was conducted with the administrator. The acknowledgement form was signed and dated by the administrator. Please complete the 'Plan of Correction' and 'Date to be Corrected' for each violation cited on the violation notice and return it to me within 10 calendar days from today. You need to be specific with how the deficiencies either have been or will be corrected to bring you into compliance with the Standards. Your plan of correction must contain the following three points: 1. Steps to correct the noncompliance with the standard(s) 2. Measures to prevent the noncompliance from occurring again 3. Person(s) responsible for implementing each step and/or monitoring any preventive measure(s) Please provide your responses in a Word Document, if possible. Plan of correction is due with 10 days- 9-28-18.

Standard #: 22VAC40-73-680-D
Description: Based on record review and staff interview, the provider failed to ensure staff administered medication consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing when administering medication to a resident. Evidence: 1. On 7-30-18, during the inspector's interview with staff #1 regarding a ?medication error reported on 7-29-18 in which it was reported that staff #1 administered another resident's Synthroid 50 mcg tablet to resident #1?, staff #1 stated, "the medication error was discovered after returning to the medication cart to document the information on the resident?s medication administration record (mar).? Staff #1 stated looking at the medication administration record (mar) and noticed that the wrong resident had been administered Synthroid medication that was not prescribed for a resident, (resident #1.)? 2. The inspector asked staff #1, did staff not check to ensure staff had the right person and the right medication, staff #1 stated the incident occurred as follows: a. ?Staff looked at the mar for room 212, pulled the Synthroid and went to room 212 to administer the medication to the current resident in the room (resident #1)?. b. According to staff #1, resident #1 stated ?not getting medication at that hour (5:30 am); resident #1 stated receiving medication which is three pills on the way to breakfast. Staff stated encouraging resident to take medication that physician had prescribed." c. The inspector asked staff #1 when resident #1 stated not receiving medication at that hour and was upset about being awaken at such hour (as stated by staff #1 during the interview) was the resident refusing to take the medication?. Staff #1 stated, resident #1 did question staff #1 about the medication. However, staff #1 stated she had already pulled the medication and also encourage resident #1 to take the medication. d. During further interview with staff #1, the inspector asked if staff looked at the resident?s photo to help identify the resident, staff stated ?did not see a photo on the mar". When asked about the name on the door, staff #1, did not look at the name on the door to room 212. Staff #1 also stated to the inspector that ?staff #1 was not familiar with the assisted living side of the facility because staff #1 normally worked the memory care unit (special care unit/scu). 3. A review of staff #1?s written statement dated 7-3-19 confirm staff #1?s statement to the inspector indicating ?resident asking why being awaken so early?staff informing resident to take the Levothyroxine (Synthroid)?.resident #1 informing staff #1 of taking 3 pills on the way to breakfast?resident asked staff #1 why was staff #1 doing things differently?. Staff informed resident #1 that staff #1 did not normally work the AL side (assisted living)?.Staff #1 asked resident to `please take the medication that resident #1?s doctor wanted resident to have?. 4. During the inspector?s interview with staff #2, staff #2 stated being informed by staff #1 that ?resident #1 was given another resident?s Synthroid medication on the morning of 7-29-18?.

Plan of Correction: It is Spring Arbor of Williamsburg?s policy to comply with all state regulations regarding the Administration of medications and related provisions. Registered Medication Aides will administer medications in accordance with the prescriber?s instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. All Registered Medication Aides received an in-service by Regional Nurse on the Five Rights of Medication Administration on 09/27/2018. Compliance Date: 09/27/2018

A compliance history is in no way a rating for a facility++.

The online compliance history includes only information after July 1, 2003. In addition, the online compliance history includes information regarding adverse actions that may be the subject of a pending appeal. An adverse action is not final until a provider has exhausted or waived all due process rights. For compliance history prior to July 1, 2003, or information regarding the status of pending adverse actions, please contact the Licensing Inspector listed in the facility's information. The Virginia Department of Social Services (VDSS) is not responsible for any errors in or omissions from the compliance history information.

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