VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brightview Great Falls
10200 Colvin Run Road
Great falls, VA 22066
(703) 759-2513

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date:

Complaint Related: No

Violations:

Standard #:	22VAC40-73-680-I
Description:	Based on a review of Medication Administration Records (MARS) the facility failed to ensure that The MAR shall include: diagnosis, condition, or specific indications for administering the drug or supplement. Evidence: For Residents #1, #2, #3, and #4 the diagnosis, condition, or specific indications for administering the drug or supplement were missing for prescribed medications.
Plan of Correction:	1) Steps to correct the non-compliance: Medication orders for residents #1, #2, #3, #4 were reviewed and corrected on July 25, 2019 to include diagnoses and/or specific indications for administering the drug. 2) Measures to prevent the non-compliance: An audit of medication orders for residents will be completed to ensure orders include diagnosis, condition, or specific indications for administering the drug or supplement. Wellness Nurses, medical director, and nurse practitioner to be educated on ensuring new orders included diagnosis, condition, or specific indications for administering the drug or supplement. 3) Person responsible for implementing and/or monitoring: A 20% audit of medication orders to take place monthly for 3 months, to review orders for comprehensiveness. Corrective action will be initiated for any variances and findings will be reported to the Health Services Director. Person responsible for implementation: Health Services Director or designee (11/5/2019).
Standard #:	22VAC40-73-680-K
Description:	Based upon a review of resident's records, the facility failed to ensure that that the use of PRN medications is prohibited, unless one or more of the following conditions exist: Medication aides administer the PRN medication when the facility has obtained from the resident's physician or other prescriber a detailed medication order. The order shall include directions as to what to do if symptoms persist. Evidence: The physician's or other prescriber's orders for "as needed" (PRN) medications did not include what to do if symptoms persist for the following residents: Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5.
Plan of Correction:	1) Steps to correct the non-compliance: PRN orders for residents #1, #2, #3, #4, #5 reviewed and corrected on August 6, 2019 to include directions on what to do if symptoms persist. 2) Measures to prevent the non-compliance: An audit of PRN medication orders for residents will be completed to ensure orders include what to do if symptoms persist. Wellness Nurses, medical director, and nurse practitioner to be educated on practices related to PRN medication orders, including ensuring that PRN orders include directions as to what to do if symptoms persist. Medication Aides to be educated on practices related to PRN medications administration, including steps to take after PRN medications are administered. 3) Person responsible for implementing and/or monitoring: A 20% audit of PRN medication orders to take place monthly for 3 months, to review PRN orders for comprehensiveness. Corrective action will be initiated for any variances and findings will be reported to the Health Services Director. Person responsible for implementation: Health Services Director or designee (11/5/2019).