VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Pearl at Watkins Centre
650 Watkins Centre Parkway
Midlothian, VA 23112
(804) 893-0067

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: April 17, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced inspection was made to the facility on 4/17/2019 by two licensing representatives to investigate two complaints in regards to medication administration, incident reporting and resident care/falls. The allegations were determined to be valid. During the investigation, other violations were found and cited unrelated to the complaints. The facility has 10 calendar days from receipt of the inspection reports to complete a plan of correction, sign the inspection reports and return them to the licensing office. A copy of the inspection reports shall be retained to be posted at the facility. Results of the inspection are subject to public disclosure and will be posted on the VDSS website within 15 calendar, regardless of whether the plan of correction is completed .Just writing the word ?corrected? is not acceptable. The plan of correction shall include the following: (1) Step(s) the facility will take to correct the violations cited; (2) Measures that will be put in place to prevent reoccurrence of each violation; (3) Person(s) responsible for implementation and monitoring of preventive measures; and (4) Date by which each violation will be corrected.

Violations:

Standard #:	22VAC40-73-1080-A
Complaint related:	No
Description:	Based on a review of three resident files, it was determined that one resident was admitted and retained in a safe, secure environment without documentation of a serious cognitive impairment due to a primary psychiatric diagnosis of dementia. Evidence: The Assessment For Serious Cognitive impairment for resident #1 dated 2/1/2019 and completed prior to admission the resident did not have a serious cognitive impairment due to a primary diagnosis of dementia.
Plan of Correction:	ED will ensure the Assessment for resident # 1 is reviewed and updated to accurately reflect his need to be retained in a safe,secure environment due to a serious cognitive impairment. ED or designee to review admission paperwork to verify all documentation is accurately completed.
Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on a review of the progress notes and incident reporting forms provided for resident # 1, the facility did not report two incidents within 24 hours to the regional licensing office that negatively affected the health and safety of the resident. Evidence: Resident # 1 was (1) given another resident?s medication in error on 4/3/2019 and (2) had a documented fall in February 2019 that required emergency room treatment. There was no documentation found to support that the two incidents were reported to the regional licensing office.
Plan of Correction:	ED or designee to ensure that incidents as per regulation are reported within the 24 hour time frame. ED, RDO and Quality Assurance Manager will randomly audit incident reports and verify that all state reportable incidents are reported to the licensing office within the required regulatory timeframe.
Standard #:	22VAC40-73-325-A
Complaint related:	Yes
Description:	Based on a review of three resident files on 4/17/2019, it was determined that a written fall risk assessment was not completed at the time of completion of the comprehensive service plan for three residents. Evidence; 1. The initial service plans for residents # 1, # 2, and # 3 documented that the residents were "fall risks". A fall risk rating was not found in the files of residents o# 1, # 2 and # 3.
Plan of Correction:	Ed or designee to ensure initial and subsequent fall assessments are done. ED, RDO and Regional Director of Nursing will conduct random chart audits to ensure the fall risk assessments are being completed at the time of completion of the comprehensive service plan.
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on a review of three resident files on 4/17/2019, it was found that one individualized service plan was not signed and dated by the resident?s responsible party. Evidence: The file reviews found that the comprehensive service plan for resident # 2 dated 11/2/2018 was not signed by the resident?s responsible party. This is a repeat violation as the facility was found to not be in compliance with this standard during an inspection at the facility on 2/27/2019.
Plan of Correction:	ED or designee to get signature via 1:1 with families or send via email or mail, whatever is most convenient with the families ED, RDO and Regional Director of Nursing will randomly audit resident charts and verify that all required signatures are obtained on the service plans within the state required time frame.
Standard #:	22VAC40-73-530-C
Complaint related:	No
Description:	Based on an inspection at the facility and an interview with the facility?s administrator on 4/17/2019, four residents do not have freedom of movement to their personal spaces. Evidence: The Facility?s administrator reported that the doors to four resident rooms continue to be locked from the outside per family request. An electronic key (fob) is required to access the rooms. The residents do not have access to the fob key,the fob key is in possession of a family member or a facility staff member. The residents cannot access the rooms without the presence of the family member or a facility staff member with the fob key. An inspection of the facility on 4/17/2019 confirmed that the doors to the rooms for the four residents (# 4, # 5, # 6, # 7) are locked from the outside. This is a repeat violation as the facility was found to mot be in compliance with standard 22VAC 40-73-530.C during an inspection at the facility on 4/3/2019.
Plan of Correction:	An allowable variance has been submitted for review. Families have put their dissatisfaction in writing and also requested doors be locked as it is an invasion of their privacy for other residents walking in their loved ones rooms.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on an interview with a family member, a medication pass observation and a review of documentation in the file of resident #1 on 4/17/2019, it was determined that medication was not administered consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. A family member of resident # 1 was visiting the resident at the facility on 4/3/2019 when staff # 1 approached the resident to administer medication. Staff # 1 addressed resident # 1 using a wrong name (resident # 8) and was corrected by the family member. Staff # 1 left and returned shortly after and informed the family member that the medication was for resident # 1. Staff # 1 administered the medication in the presence of the family member. The medication (hydroxyzine according to the facility's administrator) was prescribed for resident # 8, not resident # 1. Staff # 1 failed to adhere to the standards of practice for registered medication aides in administering medications- ensuring that the right person receive the right medication. 2. During a medication pass observation on 4/17/2019, licensing staff observed staff # 2 placing pills for resident # 1 in applesauce. Staff # 2 informed licensing staff that the pills were placed in applesauce because the resident has problems swallowing. A review of the file for resident # 1 did not find any documentation to support that the facility had adhered to the standards of practice by consulting with the pharmacy or resident's physician regarding the use of applesauce. 3. Staff # 2 did not have any applesauce available for use in administering the medication. After removing the medication from the packaging staff # 2 had to ask another staff to secure applesauce from the kitchen. Staff failed to adhere to the standards of practice by ensuring that adequate supplies were available for safe/disruptive medication administration.
Plan of Correction:	Not available online. Contact Inspector for more information.