VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Tall Oaks Assisted Living
12052 N. Shore Drive
Reston, VA 20190
(703) 834-9800

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: July 26, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced complaint inspection was conducted on 7/26/19, in response to a complaint that was received by the licensing office on 7/15/19 regarding resident care and related services. Resident records were observed and medication administration records were reviewed. The complaint was deemed valid, as a preponderance of evidence supported the allegation. The violations were discussed and an exit meeting was held. The violation was discussed and an exit meeting was held. Areas of non-compliance are identified on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-650-A
Complaint related:	Yes
Description:	Based on documentation, the facility failed to ensure that no medication or dietary supplement is started, changed, or discontinued without a valid order from a physician or other prescriber Evidence: The record for Resident #1 contained a physician's order, dated 5/20/19, that called for the resident to receive alternating daily doses of Lasix (40mg and 80mg) for Edema. The order specified that the resident should receive four doses of Lasix 80mg, and then the resident should resume a daily dose of Lasix 40mg. The medication administration record (MAR), for Resident #1, indicates that the resident received her last 80mg dose of Lasix on 5/29/19. Lasix 40mg was administered on 5/30/19, but the daily dose of 40mg was not resumed. On 7/8/19, Resident #1 was sent to the hospital after complaining of pain and swollen feet. Later that day, Resident #1 was discharged from the hospital. The discharge diagnosis was Peripheral Edema. Resident #1's record contains an order, dated 6/18/19, for the resident to stop taking Celebrex. Resident #1's MAR indicates that she continued to receive Celebrex until 6/29/19. Resident #1's record contains an order, dated 7/9/19, for the resident to stop taking Ferrous Sulfate. Resident #1's MAR indicates that she continued to receive Ferrous Sulfate until 7/12/19.
Plan of Correction:	The order was discontinued in the MAR after the alternating daily doses were completed. The Pharmacy failed to enter the order in its entirety, resuming the 40mg daily dose. Medications continued to be delivered to the community but were not placed into the med cart because there was no order entered into the system for the medication. As a result of this discrepancy the facility has appropriately taken steps to correct and reduce/eliminate occurrences by increasing training sessions. These will be provided by the pharmacy, Director of Nursing, and others as deemed necessary. The Director of Nursing and/or Assistant Director of Nursing will review and audit charts to ensure accuracy. This will be on-going. Although medication was discontinued per the doctor's order, and not administered to the resident, the LPN continued to document that it was given. Medication was taken from the med cart and stored in the closet to be discarded. The discarded/discontinued medication was given to the Executive Director for proof that it wasn't given to the resident. As a result of this discrepancy the facility has appropriately taken steps to correct and reduce/eliminate occurrences by increasing training sessions. These will be provided by the pharmacy, Director of Nursing, and others as deemed necessary. The Director of Nursing and/or Assistant DIrector of Nursing will review and audit charts to ensure accuracy. This will be on-going. The physician's order indicating that the medication could be discontinued effective 7-9-19 was not faxed to the pharmacy until 7-11-19 when it was discovered by the (former) Director of Nursing. When this was discovered it was faxed and medications were discontinued. As a result of this discrepancy the facility has appropriately taken steps to correct and reduce/eliminate occurrences by increasing training sessions. These will be provided by the pharmacy, Director of Nursing, and others as deemed necessary. The Director of Nursing and/or Assistant Director of Nursing will review and audit charts to ensure accuracy. This will be on-going.
Standard #:	22VAC40-73-680-H
Complaint related:	No
Description:	Based on record review, the facility failed to document on a medication administration record (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements. Evidence: Resident #1's MARs (May - July) were reviewed during the inspection. The Uniform Assessment Instrument (UAI) for Resident #1, dated 10/3/18, states that the resident needs medications to be administered/monitored by professional nursing staff. Resident #1's record contained an order for Boost in June 2019. The June and July MARs, for Resident #1, did not contain documentation about the administration of the resident's Boost. No documentation was included on Resident #1's MAR, to document the administration of Mirtazapine or Simvastatin on 6/10/19.
Plan of Correction:	Order to discontinue order from the doctor effective 7-26-19. Nurses will continue to monitor resident orders, communicate with the doctors, family members, and other team members to ensure that orders are entered into the EMAR system and medications or supplements with a valid order are administered as prescribed. The Director of Nursing and/or Assistant Director of Nursing will review and audit charts to ensure accuracy. This will be on-going.