VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Banister Residential Care Facility, Inc.
1017 Bethel Road
Halifax, VA 24558
(434) 476-8811

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: June 25, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

The facility received technical assistance on the following: 520E - at least 11 hours of scheduled activities available to the residents each week for no less than one hour each day; 520I - written activities' schedule meeting the criteria; 530A - any resident who does not have a serious cognitive impairment shall be allowed to freely leave the facility; and 560E - all resident records shall be kept in a locked area.

Comments:

This monitoring visit resulted from violations received during April's 2019 inspection. At 1:12 pm the inspection commenced and concluded at 3:54 pm. Two violations were cited, with both being repeats. Six residents were in care. During the inspection, the LI reviewed the medication administration record and conducted interviews. After the inspection, the LI and staff reviewed the violations and provided an opportunity for open discussion. The LI is available via email, adina.pogue@dss.virginia.gov Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word corrected is not acceptable. Your plan of correction must contain the following: 1) steps to correct the noncompliance with the standard(s); 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on documentation review and staff interview, the facility failed to implement the medication management. Evidence: 1. Resident 1 is prescribed Ferrous Sulfate 325 mg tab. Between 5/13/19 - 5/17/19, 3 doses were not given due to waiting on a refill. Resident 1 is prescribed Budesonide inhaler. Between 5/14/19 - 5/22/19, 14 doses were not given due to no refill/waiting on physician. Resident 1 is prescribed Topirate 100 mg tab and Tamsulosin HCL .4 mg capsule. Between 6/15/19 - 6/17/19, 7 doses were not given due to waiting on a refill. Staff 1 confirmed the facility did not secure a refill in time to prevent missed doses.
Plan of Correction:	The administrator shall implement in the medication management policy and procedure plan when to call in prescriptions to aviod the residents from running out and missing doses. All staff shall read and sign that they understand the medication plan and procedures. The staff shall communicate verbal as well as document when medications has been called in for refills and the next day follow up and check refill repeat steps daily until medication has been shipped and delivered to the facility.
Standard #:	22VAC40-73-680-I
Description:	Based on residents' records review, the facility failed to ensure MAR (medication administration record) documentation included all the required components. Evidence: 1. On 5/25/19, four medications for resident 2 had one set of initials marked out and another one added above. There was no note indicating what occurred. 2. Resident 3 is prescribed vitamin d3. On 4/24/19, there are initials with the word error written above it. There is no note indicating what error occurred. On 5/3/19, there was on set of initials marked out and another one added above. There was no note indicating what occurred. 3. Resident 4 is prescribed ibuprofen 800 mg PRN. On 5/20/19, it was administered but the facility failed to document the medication's effectiveness.
Plan of Correction:	Staff shall explain reasons for any circles or any crossed out marks or errors on the back of the MAR. Staff shall document effectiveness of any and all Prn medications on the back of the MAR when given. The administrator shall routinely monitor the MAR booklet to avoid repeated violations.