VIRGINIA DEPARTMENT OF SOCIAL SERVICES

COMMONWEALTH SENIOR LIVING AT HAMPTON
1030 TOPPING LANE
Hampton, VA 23666
(757) 826-3728

Current Inspector: Darunda Flint (757) 807-9731

Inspection Date: July 11, 2019 and July 16, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced focused monitoring inspection was conducted by the Licensing Inspector from the Eastern Regional Office on 07-11-2019 from 9:30 AM to 3:20 PM and on 07-16-2019 from 10:00 AM to 12:08 PM. There were 89 residents in care at the time of the inspection. A spot check of the medication carts were reviewed on the assisted living and women's special care units. The following was reviewed: the facility's medication plan policies, medication administration records, physician's orders, and 3 staff records. Interviews were also conducted with staff and residents. The following was discussed with the Administrator and Assistant Administrator throughout the inspection: Electronic MAR system regarding controlled substances, documentation and disposal of controlled medications, and physician's orders. The facility received violations "under" resident care and related services. The areas of noncompliance were discussed with the Administrator and Assistant Administrator throughout the inspection and during the exit interview. 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, 08-12-2019. 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 measure.

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on observation, record review, and interview, the facility failed to implement the facility's medication plan to include a plan for proper disposal of medication. Evidence: 1. On 07-11-2019, staff #2 provided a copy of the facility?s ?Outdated, Damaged, or Contaminated? medication plan policy dated 02-01-2019. This policy documented ?Outdated, damaged, or contaminated medications will not be given to any resident? Outdated, damaged, or contaminated medications are not to be used and are to be disposed. Med Aides are responsible for identifying outdated, damaged, or contaminated medications.? 2. On 07-11-2019, during review of the medication carts with staff #3 and staff #4, the following was observed: a. The women?s special care unit medication cart contained resident #2?s bottle of Tramadol 50mg with a ?Use before? date of 05-11-2019. The bottle also contained a label which read ?Discard on 7/5/2019 or sooner if otherwise indicated.? Additionally, resident #2?s May and June 2019 Medication Administration Record (MAR) documented that the resident received the Tramadol 50mg tablets after the medication expired on 05-16-2019 and on 06-19-2019. b. The assisted living medication cart contained resident #3?s bubble package of Tramadol 50mg with an expiration date of 06-28-2019. 3. During interview on 07-11-2019, staff #1, staff #2, and staff #3 acknowledged the aforementioned medications for resident #2 and resident #3?s were expired and not disposed of.
Plan of Correction:	What Has Been Done to Correct? Medication was removed immediately. All RMA?s have been trained on medication administration to follow medication management plan. How Will Recurrence Be Prevented? Medication Observation Pass and cart audits will be conducted weekly and at random to assure regulatory compliance is met. Person Responsible: RCD, ARCD, and or Designee
Standard #:	22VAC40-73-680-D
Description:	Based on record review and interview, the facility failed to ensure medications were administered in accordance with the physician's instructions. Evidence: 1. On 07-16-2019, During resident #1?s record review with staff #1 and staff #2, the resident had two physician?s orders dated 04-18-2019 and 06-21-2019 for Hydrocod/APAP 5-325mg (Norco)- 1 tablet by mouth every 6 hours, and Hydrocod/APAP 5-325mg (Norco)- 1 tablet by mouth every 4 hours as needed for pain. 2. Resident #1?s June and July 2019 Medication Administration Record (MAR) documented the Norco 325mg tablet was to be administered at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM; however, it is documented that the scheduled medication was not administered from 06-20-2019 through 07-07-2019 due to ?Awaiting Pharmacy? and ?Invalid Med (DC?d or no RX). Staff #2 stated resident #1 ran out of the scheduled Norco 325mg tablet and the staff administered the PRN Norco 325mg tablet in place of the scheduled Norco. Upon further review, the June and July 2019 MAR documented the scheduled Norco 325mg tablet was not administered to resident #1 every 6 hours in accordance with the physician?s instructions. The June and July 2019 MAR documented the scheduled Norco 325mg tablet was not administered during the following scheduled times, to include no administration on June 21, 2019: a. The 12:00 AM dose on 06-20-2019, 06-22-2019, 06-24-2019, 06-25-2019, 06-27-2019, 06-28-2019, 07-04-2019, 07-05-2019, 07-06-2019, and 07-07-2019; b. The 6:00 AM dose on 06-20-2019, 06-24-2019, and 06-26-2019; c. The 12:00 PM dose on 06-20-2019, 06-24-2019, 06-30-2019, 07-02-2019, 07-03-2019, 07-04-2019, and 07-05-2019; and d. The 6:00 PM dose on 06-21-2019, 06-22-2019, 07-03-2019, and 07-06-2019. 3. During interview on 07-16-2019, Staff #1 and staff #2 acknowledged the staff did not administer resident #1?s scheduled Norco every 6 hours in accordance with the physician?s instructions based on the June and July 2019 MAR?s.
Plan of Correction:	What Has Been Done to Correct? Medication were discontinued at prescribers? request/order. Reeducate all RMA?s on following prescribers? orders. How Will Recurrence Be Prevented? Medication Observation Pass and cart audits will be conducted weekly and at random to assure regulatory compliance is met.. Order will be reflected on MAR. Person Responsible: RCD, ARCD, and or Designee