VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Stratford House
1111 Main Street
Danville, VA 24541
(434) 799-2266

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: June 17, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

On 6/17/2019 one inspector conducted a complaint investigation (1pm to 3pm) concerning a resident not receiving medication. The medication was supposed to have been stopped for two days prior to surgery. When the surgery was cancelled, the facility did not contact the physician regarding starting the medication again. Based on available evidence, the complaint is valid/founded. Please respond to the violation notice by 7/22/2019. Call the inspector if you have questions.

Violations:

Standard #:	22VAC40-73-460-A
Complaint related:	Yes
Description:	Based on interviews and document review, the facility failed to assume general responsibility for the health, safety, and well-being of a resident. EVIDENCE: 1. The facility did not follow up on medications for resident 1 when a scheduled surgery was cancelled. Resident 1 had surgery scheduled for 5/22/2019 (ordered 5/9/2019), and on the same day, an order was written to discontinue Eliquis two days prior to surgery. The Eliquis was stopped 5/20/2019, as ordered. The surgery, scheduled for 5/22/2019 was cancelled, and the facility has not charted this, and did not contact the physician in a timely manner to begin administering Eliquis again. An interview with resident 1 reveals that he does not keep up with what medications he gets, and he stated the surgery was cancelled because of blood work showing a deficiency in a mineral. An order was signed on 5/28/2019 for Klor-Con 10 to correct the deficiency. Staff interview confirms that surgery was cancelled due to low potassium levels. On 5/29/2019 it was discovered by a non-facility person that the Eliquis had not been restarted, and that no one in the facility contacted the physician about restarting it.
Plan of Correction:	Medication for resident one was put in place correctly. Resident Care Director consulted with the physician for resident. One. Moving forward, the physician will fax all orders from visits to the facility. The residents have been keeping new orders. In order to ensure overall compliance moving forward, the RCD or designee in her absence will review all new orders for accuracy and implementation. We have conducted a complete MAR to Cart audit and a complete Chart to Mar audit with our pharmacy. The RCD will be responsible to ensure MAR audits on an on-going basis.