VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brightview Woodburn
3450 Gallows Road
Annandale, VA 22003
(703) 462-9998

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: April 23, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Licensing Inspector (LI) conducted unannounced complaint investigation on 4/23/19 regarding alleged resident abuse and neglect. . LI reviewed resident record, medication administration records and interviewed the resident. LI also spoke with the Executive Director. While the preponderance of evidence gathered during the investigation did not support the allegations, violations were found and cited. LI also conducted a focused inspection of self-reported incidents submitted by the facility. LI reviewed resident records, medication administration records, and progress notes. LI spoke with the Executive Director and violations were cited. The Executive Director signed the acknowledgement of inspection at the exit interview. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via email at jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-650-B
Complaint related:	No
Description:	Based upon a review of the medication administration records (MARS) and physicians orders, the facility failed to ensure that the physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall identify the diagnosis, condition, or specific indications for administering each drug. Evidence: Resident #1's MARS did not include the diagnosis, condition, or specific indications for administering the routine medications. Resident #2's MARS did not include the diagnosis, condition, or specific indications for administering Clonazepam Tab 1mg and Milk of Magnesium SUSP 1200mg/15ML.
Plan of Correction:	An audit of 100% of all medication orders will be performed by Health Services Director (HSD) or designee. The HSD or designee will obtain diagnoses for any medication orders currently missing diagnoses. Moving forward, the HSD or WN will not accept any orders without diagnoses and will obtain clarification for diagnoses before submitting such orders to the pharmacy. On a monthly basis, a designated nurse will be assigned the responsibility to review, edit and update all orders, and sign and date the MARs to indicate accuracy; this review will be performed in QuickMAR. Date to be corrected: 6/1/19 and on-going
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based upon a review of Medication Administration Records, progress notes, and interview with administration, the facility failed to ensure that medications shall be administered in accordance with the physician's or other 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. Evidence: From March 28, 2019 through April 7, 2019, Resident #2 received 0.5mg of Clonazepam at 8:00 am. The physicians orders written March 27, 2019 stated that Resident #2 is to receive 1mg of Clonazepam two times a day (8 am and 8 pm).
Plan of Correction:	Medication Technician (MT) involved in medication error was counseled and re-trained on 4/09/19. Resident?s primary care physician, ordering physician for the clonazepam, and responsible party were all notified at time error was noted by the Health Services Director (HSD). The 0.5 mg dose of clonazepam was also removed from the medication cart at time error was noted. Health Services Director (HSD) will re-train all certified medication technicians (MTs) on the six rights of medication administration at the next MT meeting. The Nurse will remove discontinued medications from the medication cart at time of order change moving forward. Date to be corrected: 5/31/19
Standard #:	22VAC40-73-680-H
Complaint related:	No
Description:	Based upon review of Medication Administration Records (MARS), the facility failed to ensure that at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements. Evidence: Under the pass notes on the Medication Administration Records (MARS) for Resident #1 it was stated that on March 30, 2019, Modafinil 100mg was given on time but the entry on the MARS was late. On March 31, 2019, under the pass notes on the MARS the following medications for Resident #1 were documented as being administered on time but with a late entry onto the MARS: Enalapril Tab 10mg, Aspirin EC Tab 81mg, Coenzyme Q10 cap 200mg, Bupropion Tab 100mg, Multivitamin Tab, Vitamin B-12 1,000mcg, Vitamin D3 Tab 1,000u, and Ventolin HFA Inhaler. On April 19, 2019, under the pass notes on the MARS, it was stated that the following medications were given on time but the entry on the MARS was late: Enalapril Tab 10mg, Coenzyme Q10 200mg, Multivitamin Tab, Bupropion Tab 100mg, Vitamin B-12 1,000mcg, and Vitamin D3 Tab 1,000u.
Plan of Correction:	Medication Technicians (MTs) involved in the violations were counseled and re-trained on documentation and timely medication administration. Health Services Director (HSD) will re-educate all certified medication technicians regarding on time delivery of medications at the next Med Tech meeting. The HSD will also review the times of scheduled medication administration for each medication technician to ensure that the MT assignments are balanced and that the on- time administration can be completed and sustained. Date to be corrected: 5/31/19