VIRGINIA DEPARTMENT OF SOCIAL SERVICES

English Meadows Crozet Campus
1220 Crozet Avenue
Crozet, VA 22932
(540) 810-6200

Current Inspector: Tamara Watkins (804) 662-7422

Inspection Date: Oct. 23, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced focused inspection was conducted on 10/23/19 by 2 licensing inspectors from approximately 11:10 a.m. - 12:20 p.m., to follow up on a self reported incident involving a medication error. During the inspection, 1 resident record was reviewed, 1 staff training record was reviewed, medication administration record (MAR) and physician orders were reviewed, facility documentation was reviewed and staff interviews were conducted. An exit meeting was held with the administrator. A violation was cited during this inspection. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the Inspector within 10 days. 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: 1) steps to correct the non-compliance 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). Please contact me by e-mail at T.Lesley@dss.virginia.gov if further assistance is needed.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on review of resident records, facility documentation and interviews with staff, the facility failed to ensure that all resident medications be administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1) Resident #1 received a physician order on 10/9/19 for Potassium Chloride ER 20 MEQ to be given once daily as a supplement, which was scheduled to start on 10/10/19 (as recorded on the medication administration record), however the resident missed the first scheduled dose on 10/10/19. The first dose was administered on 10/11/19. 2) The administrator confirmed during interview that staff #1 received disciplinary actions for not administering the Potassium Chloride ER 20 MEQ to resident #1 on 10/10/19, and not following proper guidelines and standards for medication administration. 3) During the inspection, proof of in-service training conducted on 10/12/19 with staff #1 on medication administration guidelines was reviewed by the licensing inspector.
Plan of Correction:	Medication aides and LPN's will be observed during a medication pass by DON, ARCC or Administrator monthly to ensure compliance with medication management plan. Facility will ensure that all new orders received from physicians will be started within 24 hours of signature. Resident care staff will be in-serviced on facility medication management plan to ensure compliance with regulation.