VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Abingdon
860 Wolf Creek Trail NW
Abingdon, VA 24210
(276) 628-1621

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: Dec. 3, 2018

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Two licensing inspectors conducted an unannounced focus monitoring inspection as well as a self reported medication error at Commonwealth Senior Living Abingdon on 12/03/2018. The inspection started at 2:15pm and concluded 2:50 pm. The purpose of this inspection was to determine compliance and correction of previously cited violations. A tour of the building was conducted and resident filed were reviewed. All violations from the previously inspection were found to be corrected and in compliance with current standards. One violation was issued during this visit due to the self reported medication error. An exit meeting was conducted with the facility administrator on 12/03/2018 and at that time opportunity was given to find items that could not be located in the files. Please provide a plan of correction and date to be corrected for the one violation cited and return a signed and dated copy of the violation notice back to your licensing inspector within ten calendar days (12/14/2018) of receipt. If you have any questions or concerns please contact your inspector at 276-608-1067. Thank you for your cooperation and assistance in this matter.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on documentation and staff report, the facility failed to administer medications in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. Staff #1 reported Staff #2 gave the following medications to Resident #1 in error: Acetaminophen 325mg, Zyrtec 10mg, Lasix 20mg, Labetalol 200mg, Lisinopril 10mg, Potassium 10mcg, Primidone 50mg, and Topamax 50mg. 2. Staff #2 reported she was rushed and walked into the wrong resident room by mistake and gave Resident #1 the previously mentioned medications in error. 3. Resident #1 was sent to a local hospital Emergency Department for evaluation and admitted to the hospital for observation according to the hospital admission notes. 4. During Resident #1's hospital stay, there were no adverse effects to the incorrect medications that were administered according to the hospital documentation. 5. Resident #1 was discharged back to the facility 11/17/2018 according to the hospital discharge summary.
Plan of Correction:	Resident Care Director followed up with all Responsible Party and Physician's for Resident #1 report the medication error. There were no adverse reactions noted from the medication error per the hospital record. All nurse's and RMAs re-educated on the medication management policy regarding medication administration in accordance with physician instructions. Executive Director, Resident Care Director, or designee will ensure adherence to the medication management policy. Random monitoring of compliance will be completed at a minimum x4 weeks by the Executive Director, Resident Care Director, or designee to ensure continued compliance. In-service proper of medication management conducted with all nurses and RMAs by 12/14/2018. [sic]