VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Discovery Commons Virginia Beach
1628 Old Donation Parkway
Virginia beach, VA 23454
(757) 496-8001

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: June 24, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

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Comments:

An unannounced monitoring inspection was conducted on this date from 8:25a.m until 2:55p.m. There were 79 residents in c are. A staff records was reviewed. Also the background checks and sworn disclosures on all staff hired (17)since the last inspection was reviewed. Three discharged sheets and seven resident records were reviewed . There was discussion about analyzing the falls and considering different strategies/inventions to prevent falls Hospice services are listed in detail. Monitor residents declining closely to ensure retention is appropriate for the facility. Monitor meal consumption of any resident choosing not to eat meals consistently in the dining . Medication observations are required by supervisor and remember the who, what, when, and where. Please complete the ?plan of correction? for each violation cited on the violation notice and return it to me within 10 calendar days from today on 7-8-19 You will need to specify how the violation will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must include: 1. steps to correct the noncompliance 2. measures to prevent reoccurrences 3. Person(s) responsible for implementing and monitoring each step of the corrective measures and / or the preventative measures

Violations:

Standard #:	22VAC40-73-440-A
Description:	Based on record review and interview the facility failed to ensure one of five residents uniform assessment instruments(UAI) in the record sample had been reassessed when there was a significant change in the resident's condition. Evidence 1. During a review of the resident records with staff #1and #2 , the inspector found resident #7's UAI dated 2-15-19 indicated the resident was only dependent in one activity of daily living ( bathing) and required mechanical and human assistance and the resident only required mechanical help with toileting and transferring. 2. Resident #7's individualize service plan updated 6-12-19, indicated the resident was receiving 24 hour care from an agency staff due to falls . The resident was also receiving skilled nursing and personal care aide services from a hospice agency . 3. Staff # 2 acknowledged resident #7 had declined and no longer met the criteria for the assisted living section and resident #7's UAI reviewed on file at the time of the inspection(6-24-19) did not address the significant change in the resident's condition.
Plan of Correction:	1. On 7/1/19 the UAI was reviewed and updated for Resident #7 to assure it appropriately reflected this resident?s current needs. 2. An audit of UAI?s for current residents at the community will be completed by RSD and LGD or designee to assure that all UAI?s accurately reflect the residents? needs. This audit is to be completed by 9/30/19. Any changes or updates necessary based on the audit findings will occur at time of review. 3. Training will be provided by the Divisional Director of Care to RSD, RSS, LGD, and ED on completing the UAI accurately to reflect the needs of the resident as per regulatory standards. This training is to be completed by 7/12/19. 4. The RSD and LGD or designee will assure that the assessed needs reflected on the UAI are accurate for new and current residents per regulatory standards. Over the next 90 days, the ED will complete a thorough review of newly completed and/or updated UAIs to assure they accurately reflect that residents? current needs. Any updates or corrections that are needed will be addressed at time of review.
Standard #:	22VAC40-73-450-F
Description:	Based on record review and interview the facility failed to ensure one of five Individualized service plans(ISP) reviewed in the record sample had been updated as the condition of the resident changed. The update shall be performed by a qualified staff person and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons. Evidence 1. While reviewing the residents records with staff #2 and #3, the inspector found resident # 7's ISP updated 6-12-19 did not include fall prevention. 2. According to the ISP updated and signed by the family 6-12-19, agency staff would provide 24 hour care due to falls . 3. The resident notes provided by staff #2 and reviewed by the inspector indicated resident #7 had fallen on 5-28-19 and a resident care note was created 5-28-19@3:55a.m. and there was a post fall observation care note created 6-10-19@8:.03p.m. During the inspection no other fall documentation was provided . 4. Staff #3 acknowledged resident #7's , ISP dated 6-12-19 did not include fall prevention .
Plan of Correction:	1. On 7/1/19 the ISP was reviewed and updated for Resident #7 to assure it appropriately reflected this resident?s current needs including fall interventions to assist in preventing falls. 2. An audit of fall risks and fall interventions of all current residents at the community will be completed by RSD and LGD or designee to assure that all ISP?s accurately reflect the residents? needs. This audit is to be completed by 9/30/19. Any changes or updates necessary as a result of the audit will occur at time of review. 3. Training will be provided by the Divisional Director of Care to RSD, LGD, RSS, RRD and ED on completing timely fall risk reviews, assuring residents have appropriate fall risk ratings completed, and assuring residents have appropriate interventions in place as per regulatory standards. This training is to be completed by 7/12/19. 4. The RSD, RRD, and LGD or designee will assure that the assessed needs reflected on the ISP are accurate for new and current residents? per regulatory standards. Over the next 90 days, the ED will complete a thorough review of newly completed and/or updated ISPs to assure they accurately reflect that residents? current needs. Any updates or corrections that are needed as a result of that review will be addressed at time of review.
Standard #:	22VAC40-73-460-D
Description:	Based on record review and interview the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls. Evidence 1. During a review of six of nine resident records in the record sample with staff # 2 , the inspector found between 12-4-18 and 6-5-19, six of the residents had documented falls that required emergency room treatment. 2. The falls resulted in the following injures: a. resident # 9 fell on 12-4-18, fractured ribs b. resident # 8 fell on 1-23-19, fractured hip c. resident #5 fell on 6-12-19, had a laceration to the head that required 3 staples d. resident # 6 fell on 5-24-19, had a laceration to the head that required an undocumented amount of staples e. resident #3 fell 5-25-19, fractured femur f. resident #2 fell 6-5-19, broken femur 3. Staff #2 acknowledged there had been an increase in falls in recent months .
Plan of Correction:	1. At time of survey Resident #3 had moved out and Resident #6 and #8 had expired. Resident #2 and #9 are currently out of community at local rehab and will have their fall risk interventions reviewed and updated upon return. Resident #5 fall risk interventions will be reviewed and updated by 7/3/19 to assure that current care and specialized needs are being met to assist in further prevention of falls. 2. An audit of current residents? fall risk interventions will be completed by RSD, LGD and RRD to assure all residents have appropriate fall risks and interventions in place. This audit will be completed over then next 90 days. To be completed by: 9/30/19 3. Training will be provided by the Divisional Director of Care to RSD, LGD, RSS, RRD and ED on completing timely fall risk rating and assuring residents have appropriate fall risks completed and interventions in place as per regulatory standards. This training is to be completed by 7/12/19. 4. Over the next 90 days, the ED will complete random weekly audits to assure there are proper fall risks and interventions in place. Concerns observed during this audit will be addressed at that time to assure continued compliance.
Standard #:	22VAC40-73-680-C
Description:	Based on observation ,record review, and interview, the facility failed to ensure all medications were administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence 1. At 9:07 following the medication observation of the administration of resident #1's sixteen medications by staff #4 ,the inspector found four other residents had not received their medication scheduled to be administered 8 o'clock a.m. 2. While reviewing the medication record with staff # 1 , the inspector found the following residents had a total of 38 pills not administered no earlier than one hour before and not later than one hour after the facility's standard dosing schedule. Resident #13 had 12 pills , resident #14 had seven pills, resident #15 had 9 pills and resident #16 had 8 pills not administered within the facility's 8a.m dosing schedule. 3. During interview staff # 4 stated #13 is not an early riser and usually is not awake until after 9 a.m.
Plan of Correction:	1. Residents #14, 15 and 16 physicians were contacted, and an order was received to change their AM administration time to 10AM as per each resident?s preference. 2. The RSD will review current Standard Medication Times for the community to assure it allows for appropriate regulatory compliance during medication pass. RSD will complete an audit of current medication administration times for each resident currently on the medication program. Appropriate follow-up will be completed with MD?s and medication administration time changes will be made as approved by MD?s. To be completed by 7/30/19. 3. The RSD will provide in-service training to all current medication staff on medication pass and the regulations which require that medications be administered to the resident within an hour before or an hour after the community?s standard dosing schedule (or resident?s ordered med pass time, if different per MD order). Training will also address the requirement that should a resident?s medication times need to be addressed due to resident preference or potential non-compliance concerns; medication staff will send an order request, to the primary prescriber, to change the resident?s administration schedule. These trainings will be completed by 7/30/19. Moving forward new and current resident medication staff will assure medications are administered within the appropriate timeframe as per regulatory standard. 4. For the next 90 days the RSD or designee will complete random weekly med pass observations to assure continued regulatory compliance. The Executive Director (ED) will be provided a report of findings from each weekly med pass observation. Compliance concerns will be immediately addressed with the employee and appropriate corrective action will be taken up to termination when warranted.