VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Avalon House in McLean
1503 Oakview Drive
Mc lean, VA 22101
(301) 656-8823

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: Aug. 28, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced complaint inspection was conducted on 8/28/19, in response to a complaint received by the licensing office on 7/8/19, regarding admission, retention and discharge of residents; resident care and related services. Two resident records were observed. The allegations were determined to be valid, as a preponderance of evidence supported the allegations. The violations were 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 #:	22VAC40-73-470-F
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to document the circumstances involved and the notification of a resident's legal representative, when there is reason to suspect that a resident has suffered a serious injury. Evidence: CT scan results, dated 8/15/19, were included in the record for Resident #1. The reason for the exam was listed as a closed head injury. Facility staff reported that Resident #1 bumped her head on 8/15/19, but the event was not documented in the resident record. Facility staff reported that Resident #1's physician was contacted after the event, and the physician ordered the evaluation. Facility staff reported that Resident #1's legal representative was notified of the event, but the resident record did not contain documentation of the date, time, caller, or the name of the person who was notified.
Plan of Correction:	An administrator will do a training with staff regarding proper documentation in a resident's chart after an incident occurs. Administrator will check charts monthly to ensure proper documentation for incidents are in the chart.
Standard #:	22VAC40-73-560-E
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure that the resident record is kept current. Evidence: Progress notes, included in the record for Resident #2, stated that the resident was taken to the hospital on 6/19/19 and she returned with a foley catheter. The progress notes stated that the resident's foley catheter was removed on 6/23/19, after blood was found in her urine. Resident #2's ISP, revised 6/19/19, identified the resident's catheter, but did not address how Resident #2's catheter would be managed at the facility. Documentation of foley catheter training was provided for Staff #1. The hospital summary that contained foley catheter care instructions, dated 6/19/19, was not included in the resident record.
Plan of Correction:	An administrator will train staff to attach the foley catheter plan of care to the service plan. They will train them about what should be included on the ISP. The resident chart being checked was a discharged resident. Both the chart and hospital discharge forms were being kept in the same locked file cabinet. The discharge statement was given to the inspector while the inspection was still happening. Administrator will place hospital discharge records in the discharged resident's chart.