VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Tribute at One Loudoun, LLC
20335 Savin Hill Drive
Ashburn, VA 20147
(571) 252-8292

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: April 24, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Technical Assistance:

LI discussed Standard 1130 regarding the number of staff that are to be awake and on duty if there are more than 30 residents on the memory care unit.

Comments:

Licensing Inspector (LI) conducted unannounced complaint investigation on 4/24/19 regarding resident care and inadequate staffing. LI reviewed resident record, medication administration records, resident event reports, staff schedules, and interviewed resident and a family member. LI Spoke with Executive Director. Complaint regarding Standard 460-B-3 is deemed valid as a preponderance of evidence gathered during the investigation supported the allegation. Exit interview conducted on 4/23/19 and the Executive Director signed the acknowledgement of inspection form. Possible violations were discussed 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 #:	22VAC40-73-460-B
Complaint related:	Yes
Description:	Based upon review of Resident Event Reports, interviews with resident, staff, and administration, and review of resident records, the facility failed to ensure that care provision and service delivery be resident-centered to the maximum extent possible and include: prompt response by staff to resident needs as reasonable to the circumstances. Evidence: On April 23, 2019, Resident #1 pushed his pendant that alerts staff of the need for assistance. The Resident Event Report indicates staff did not respond for 28 minutes. On April 21, 2019, there is documentation on the Resident Event Report that the pendant was pushed by Resident #1 and it took 27 minutes for staff to respond. On April 14, 2019, there was a witness who observed that staff did not respond to Resident #1's pendant push and after 45 minutes of no response, the witness sought out a staff member in person for assistance with Resident #1.
Plan of Correction:	Nursing team educated on expectations of response times to be equal or less than 12 minutes. Nursing management is alerted at the 11th minute of no response via email alerts. Nursing management to investigate all excessive response reports of 12 minutes or more per Palatium Care System report. Nursing management to QA monthly during QA meetings. Front desk is also monitoring during their hours of 8am-8pm and alerting nursing team. Nursing leadership twice a week to pull or press a pendant to monitor compliance.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on a review of medication administrations records, the facility failed to ensure that the MAR shall include the effectiveness for "as needed" PRN medication. Evidence: Resident #1 was given a Pain Relief Tablet (500mg) on April 9, 2019 at 8:42 pm for pain. The effectiveness was not documented on the MARS. On April 10, 2019, Resident #1 was given a Pain Relief Table (500mg) at 6:19 am for pain and the effectiveness was not documented on the MARS. On April 23, 2019, Resident #1 was administered Biscolax 10mg suppository for constipation at 8:52 pm and the effectiveness of this medication was not documented on the MARS. On April 24, 2019, Resident #1 was given a Pain Relief Tablet (500mg) for pain at 10:26 am and the effectiveness of this medication was not documented on the MARS. On April 24, 2019, Resident #1 was administered Phenazopyridine 100mg Tablet for burning and the effective ness of this medication was not documented on the MARS.
Plan of Correction:	Nursing team educated on 5/2/19 on expectations of each PRN medication given and will be reassessed for desired effectiveness and documented accordingly. Every PRN given must have documented effectiveness on MAR. Nursing management will QA monthly for 100% compliance. Nursing management will also pull reports daily generated via Care Suite by Quick Mar to monitor compliance.