VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bickford of Suffolk
6860 Harbour View Boulevard
Suffolk, VA 23435
(757) 215-0058

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

Inspection Date: July 10, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-90 Background Checks for Assisted Living Facilities

Comments:

An unannounced inspection was conducted on 7-10-19 from 8:05 until 4:30p.m in response to allegations that the kitchen was dirty , the residents did not get enough to eat, hospice residents don't get PRN morphine medications, residents are discouraged from pushing call bells, verbal loud disrespectful altercations between staff occur , the facility had no administrator, and a resident fell out of bed and expired. The facility had an acting administrator on the day of the inspection. During the inspection breakfast and lunch were observed and the preparation of dinner was in progress. There were ample serving and extra serving observed. The kitchen was found in order. There was documentation of hospice residents receiving other PRN pain medications . Family and agency staff (some who were on site daily, multiple times a day, or weekly) and staff interviewed had not heard or observed any verbal altercations between staff . Persons interviewed described the atmosphere as homelike, pleasant , and calm. No resident interviewed indicated they could push their call bell. During the inspection call bells could be heard and staff responded . A hospice nurse had documented a resident's shallow breathing days before he expired. 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 7-27-19. 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 #:	22VAC40-73-150-B
Complaint related:	Yes
Description:	Based on interview and documentation reviewed the facility failed to ensure the licensing office and the Board of Long Term Care were notified as required. The facility failed to notify the department's regional licensing office in writing within 14 days of a change in a facility's appointment of an acting administrator. The facility failed to immediately notify the Virginia Board of Long-Term Care Administrators and the department's regional licensing office that the facility was operating without an administrator licensed by the Virginia Board of Long-Term Administrators. The acting administrator failed to notify the department's regional licensing office of his/her employment, and if his/her intentions to assume the position permanently,and submit a completed application for an approved administrator-in-training program to the Virginia Board of Long-Term Care Administrators within 10 days of employment . Evidence 1. Staff in dietary , housekeeping , nursing , and visitors interviewed during the inspection referred to staff #3 as the acting administrator . Staff #4, who was the administrator of record , was notified of the inspectors presence but was not present during any part of the inspection. Staff interviewed stated staff #4 is not on site regularly , maybe 1 or 2 days a week and is now a Regional Administrator.. 2. A poster board in the foyer identified staff #3 as the acting director(what licensing calls an administrator) . 3. Staff #3 stated she intended to apply for the AIT program upon beginning her acting role. Staff #3 provided documentation of her 6-25-19 inquiry about Long Term Care Administrator requirements . 4. As of the date of the inspection( 7-10-19) licensing nor the Board of Long tern Care had been made aware the facility was operating with an acting administrator(staff #3) nor had the acting administrator(staff #3 ) who had expressed her intent to become an administrator submitted an application for the AIT program within 10 days of employment..
Plan of Correction:	The insufficiency will be corrected as follows: ? New Director appointed on 7/16/19. ? Notified the regional licensing office and the Board of Long-Term Care Administrators of appointed Acting Administrator on 7/16/19. ? Acting administrator has submitted an application to the state for licensure. The following measures will be taken to ensure the problem does not occur again: ? Bickford Divisional Director of Operations will immediately notify to the Board of Long-term care and regional licensing department of any changes in the administrative role to avoid the break in service per the regulations. Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? ED/Divisional Director of Operations
Standard #:	22VAC40-73-290-B
Complaint related:	No
Description:	Based on observation and interview the facility failed to implement their procedure for posting the name of the current on-site person in charge, in a place in the facility that is conspicuous to the residents and the public. Evidence 1. Upon arrival to the facility at 8:05a.m the inspectors ring the door bell. 2. When staff #1 open the door the inspectors identified themselves and stated they were on site to conduct an inspection. 3. While in the foyer staff #1 stated the Regional Administrator was not present and the acting administrator had not come in yet. 4. The inspector asked staff #1 was she in charge and she responded no. She was asked where the posting of the person in charge was located and she stated she would call the nurse. 5. When staff # 2, arrived in the foyer she stated she had called the acting administrator, who should be here shortly. When asked where the posting of who was in charge was located, she pointed to the credenza near the door, walked over to credenza and search around on top of the piece of furniture before locating an index size rolodex. As she searched through the rolodex, staff #2 stated the rolodex has a picture of all the in charge staff .
Plan of Correction:	The insufficiency will be corrected as follows: ? Staff in Charge posting corrected (7/12/19) to reflect the person in charge. The following measures will be taken to ensure the problem does not occur again: ? The Divisional Director of Operations will verify and audit correct posting on next 3 branch visits and on an annual basis. Person(s) responsible to implement and monitor corrective measure to ensure compliance. ? ED/ Divisional Director of Operations
Standard #:	22VAC40-73-300-B
Complaint related:	No
Description:	Based on record review and interview the facility failed to ensure a method of written communication was utilized as a means of keeping direct care staff on all shifts informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries related to physical or mental conditions. Evidence 1. During review of shift reports with staff # 2,#3, and #5 the inspectors found the following: a. no documentation on the shift report dated 3-25-19 that resident #1, who was on hospice had expired. @8:37 p.m or that he had fallen @7:00a.m on 3-25-19 b. no documentation of resident #1's decline as noted in the hospice notes date 3-24-19 at 9:17a.m , the note indicated staff were to monitor the resident frequently due to respiratory distressed ,no evidence of monitoring was found on file during the inspection 2.Staff acknowledged the shift report did not include the significant happenings.
Plan of Correction:	The insufficiency will be corrected as follows: ? A 24-hour shift report has been implemented (6/1/19) to provide staff with significant information shift to shift. The following measures will be taken to ensure the problem does not occur again: ? Nurse Coordinators will provide training on passing down pertinent/significant information shift to shift and how to complete the 24-hour report accurately. ? Nurse Coordinators will review 24-hour report daily to ensure significant information regarding resident is being passed down shift to shift. ? The ED will perform 3 random audits of the 24 hour log for 30 days for completion and accuracy of the report. Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? ED/Nurse Coordinators/Designee
Standard #:	22VAC40-73-310-H
Complaint related:	No
Description:	Based on record review, document review, and staff interview, the facility failed to ensure it did not retain individuals with psychotropic medication without a treatment plan for two residents. Evidence: 1. On 7-10-19 during a review of resident # 2's and resident #3's record with staff # 5, it was revealed that the residents? May 2019 medication administration record (mar) noted psychotropic medication being administered. 2. A review of resident # 2's record with staff # 5 noted administration of Ativan, Zyprexa and Lexapro. Further review of resident # 2's record did not contain documentation of a treatment plan for the psychotropic medication Lexapro. 3. A review of resident # 3's record with staff # 5 noted administration of Ativan, Depakote and Zoloft. Further review of the record did not contain documentation of a treatment plan for the psychotropic medication Zoloft. 4. Staff # 5, acknowledgement treatment plans were missing for psychotropic medication for resident # 2 and # 3 .
Plan of Correction:	The insufficiency will be corrected as follows: ? Resident #2 and #3 have been brought current. All resident charts will be audited for psychotropic medications and will be addressed on ISP. The following measures will be taken to ensure the problem does not occur again: ? Admission charts and all new orders will be reviewed, and any psychotropic mediations will be entered into electronic record and faxed to the pharmacy. ? Staff training will include identifying psychotropic medications on 7/23/19. ? Evaluation and Follow up: Admission charts will be reviewed and psychotropic orders will be obtained. ? All psychotropic medications per pharmacy review will be audited quarterly for accuracy. ? The next 5 admissions ED and Divisional Director of Operations will be audited for compliance. Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? ED/Divisional Director of Operations/Nurse Coordinators
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on record review, document review, and staff interview, the facility failed to ensure the individualized service plan (ISP) contained all assessed needs for two residents. Evidence: 1. On 7-10-19 during a review of resident # 2's record with staff # 5, it was revealed the resident?s uniformed assessment instrument (UAI) dated 4-1-19 and 5-2-19 indicated wheeling and stairclimbing need assessed as not performed. A review of resident # 2's ISP dated 4-1-19 and 5-2-19 did not included these assessed needs. 2. A review of resident # 3's , record with staff # 5, revealed the 5-3-19 podiatry services were not documented on resident #3's ISP dated 1-16-19 and 3-30-19. 3. Staff # 5 acknowledged the assessed needs for resident # 2 and resident # 3 were not on the ISP.
Plan of Correction:	The insufficiency will be corrected as follows: ? Residents #2 and #3?s Individualized Service Plans have been reviewed and updated to reflect the needs of the resident. ? All team members involved in residents care have been made aware of the updates on the ISP. ? Podiatry services have been updated on the ISP (7/12/19). The following measures will be taken to ensure the problem does not occur again: ? On all new, annual or change of conditions, ISPs will be reviewed by the administrative staff (Nurse Coordinators/ED) to ensure all needs are addressed. ? ED will perform 10 random audits of ISPs over 60 Days. Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? Nurse Coordinators/ED/Designee
Standard #:	22VAC40-73-450-D
Complaint related:	No
Description:	Based on record review, document review, and staff interview, the facility failed to ensure when hospice service is provided all agreed upon services shall be included on the individualized service plan (ISP). Evidence: 1. On 7-10-19 during a review of resident #3's, record with staff # 5 and # 3, it was revealed resident was receiving hospice services beginning 1-23-19. Further review of the resident?s record revealed the hospice contract indicated nursing, social worker and aide services. A review of resident # 3's ISP did not document the social worker?s services on ISP dated 1-16-19 and 3-30-19. 2. Staff # 3and # 5, acknowledged all hospice services were not documented on resident # 3's ISP.
Plan of Correction:	The insufficiency will be corrected as follows: ? Resident #3?s ISP has been brought current to reflect the Social Worker and Aide services. The following measures will be taken to ensure the problem does not occur again: ? Nurse Coordinators will organize communication for plan of care with agencies for any resident receiving hospice services. ? Each service provided will be delineated as separate services to be provided even int eh facility staff are also providing similar services. ? Each service will be represented in a separate service need block on the ISP. ? ED will perform 10 random audits of ISPs over 60 Days. Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? Nurse Coordinators/ED/Designee
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on record review, document review, and staff interview, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee, (i.e., the person who had developed the plan), and by the resident or his legal representative. The plan shall also indicate any other individuals who contributed to the development of the plan, with the notation of the date of contribution. The title or relationship to the resident of each person who was involved in the development of the plan shall be included. These requirements shall also apply to reviews and updates of the plan. Evidence: 1. On 7-10-19 during a review of resident # 2's record with staff # 5, it was revealed the resident?s preliminary ISP dated 4-1-19 was not signed by the resident nor the resident?s legal representative. 2. Staff acknowledge the ISPs for resident # 2 was not signed by resident or legal representative.
Plan of Correction:	The insufficiency will be corrected as follows: ? A complete audit of all charts will be conducted to determine all prior UAIs/ISPs have been signed by the resident/legal representative and Executive Director. The following measures will be taken to ensure the problem does not occur again: ? Any past UAIs/ISPs found unsigned will be documented as follows: `Found on Internal Audit?. Upon completion of the UAI/ISP, the UAI/ISP will be signed by the Nurse Coordinator, resident/legal representative and the Executive Director. ? All signatures will be verified during quarterly audits. ? ED will perform 10 random chart audits to ensure prior UAIs/ISPs have been signed by resident/legal representative over 60 Days. Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? Nurse Coordinators/ED/Designee
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on record review, document review, and staff interview, the facility failed to ensure medications was administered in accordance with the physician?s order 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: 1. On 7-10-19 during a review of resident # 2's record with staff # 5 and # 2, it was revealed that the resident?s Ativan (Lorazepam) dosage was changed. The changed physician?s order, fax dated 5-10-19 at 4:06 pm indicated resident to receive ?Lorazepam, 1mg tablet, twice daily as needed for agitation?. The resident was originally prescribed Lorazepam 0.5mg, one tablet by mouth twice daily as needed for agitation. 2. A review of the facility?s controlled drug receipt record/disposition form dated May 3, 2019 indicated resident # (William) did not received the prescribed 1mg Lorazepam, on 5-11-19 5-14-19, 5-16-19, 5-19-19 and 5-21-19. The facility?s dosage available was 0.5 mg and to administer the change dosage of 1 mg, 2 (0.5mg) tablets should have been administered to equal 1mg. For the dates mentioned, staff administered 1 (0.5mg) tablet and not 2 (0.5mg) tablet per the facility?s controlled count document. 3. Further review of the controlled document for May 2019 indicated the notation indicating 2 tabs equal 1mg was updated on 5-16-19. 4. Also resident #4 was ordered Tylenol 8 hour ,three times daily .The medication was being administered at 8a.m ,noon and 5p.m daily. 4. Staff # 5 and # 2 acknowledged staff did not administer resident # 2 the 1mg dosage per the prescriber?s order change dated 5-10-19.
Plan of Correction:	The insufficiency will be corrected as follows: ? Resident #4?s Tylenol order was corrected on 7/10/19. ? Resident #2 is receiving Lorazepam as prescribed (1mg). The following measures will be taken to ensure the problem does not occur again: ? Nurse Coordinators will conduct an Inservice with all Medication Aides to ensure their knowledge of medication administration on 7/23/19. ? Random unannounced observations will be conducted by Nurse Coordinators 4 times a month for two months. Each shift: day, evening and night shift. Person(s) responsible to implement and monitor corrective measure to ensure compliance. ? Nurse Coordinators/ED