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Riverside Assisted Living at Warwick Forest
860 Denbigh Blvd.
Newport news, VA 23602
(757) 886-2000

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: Aug. 19, 2019 and Sept. 12, 2019

Complaint Related: Yes

Areas Reviewed:
22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:
An unannounced complaint inspection was conducted by two Licensing Inspectors from the Eastern Regional Office and the Peninsula Licensing Office on 08-19-2019 from 10:51 AM to 5:10 PM and by the Licensing Inspector from the Eastern Regional Office on 09-12-2019 from 11:44 AM to 4:25 PM. There were 129 residents in care at the time of the inspection. The complaint alleged concerns with Resident Care and Related Services. 1 resident record and facility policies were reviewed; and interviews were conducted. The facility received violations "under" Resident Care and Related Services. The following was discussed with the Administrator: visitation policy, resident rights, and medications. The areas of noncompliance were reviewed with the Administrator throughout the inspection and during the exit interview. Based on the information reviewed during this inspection, the complaint was found to be valid. 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, 11-02-2019.

Violations:
Standard #: 22VAC40-73-650-B
Complaint related: No
Description: Based on record review and interview, the facility failed to ensure the physician?s orders, both written and oral, for administration of all prescription and over-the-counter medications identified the diagnosis.
Evidence:
1. On 08-19-2019, during resident #1?s record review with staff #1, the following physician?s prescriptions dated 06-10-2019 did not include a diagnosis: Ferrous Sulfate 325mg, Insulin Glargine 100 unit/mL, Fluvoxamine 100mg, Quetiapine XR 50mg, Quetiapine 25mg, Pramipexole 0.125mg, Metformin 500mg, Polyethylene glycol, Cyanocobalamin 1000 mcg/ML, Donepezil 5mg, Nicotine 21mg/24hr, Omega-3 Fatty Acids 1000mg, Magnesium 500mg, Cholecalciferol 5000 units, Clopidogrel 75mg, Atorvastatin 10mg, and Amlodipine 5mg.
2. During interview on 08-19-2019, staff #1 acknowledged resident #1?s physician?s prescriptions did not include a diagnosis for the aforementioned medications.

Plan of Correction: 1. Correction was done on the day of the survey. Resident#1 records was updated by the unit manager to reflect diagnosis for the medications.

2. On the day of the survey, an immediate audit was performed by the Administrator/designee to make sure all prescribed and over the counter medication identified diagnosis noted on the physician?s orders and the Medication Administration Records and the Physician?s Orders.

3. Nurse Managers will conduct a medication reconciliation at the beginning of each month when the new MARs received from the pharmacy to ensure diagnoses are documented for all physician orders.

4. The process will be reviewed by the Administrator/designee by screening 6 residents? new orders, POSs and MARs weekly for 8 weeks to ensure diagnosis is present. All findings will be corrected and reported to the QA Committee for continued improvement and analysis.

Standard #: 22VAC40-73-650-C
Complaint related: No
Description: Based on record review and interview, the facility failed to ensure the physician's oral orders are reviewed and signed by a physician within 14 days.
Evidence:
1. On 08-19-2019, during resident #1?s record review with staff #1, a telephone order dated 06-21-2019 documented ?Increase Lantus to 20 units. Send blood sugar readings to clinic in 2 weeks.? The order did not contain a signature from the physician and was not reviewed or signed within the required 14 days.
2. During interview on 08-19-2019, staff #1 acknowledged resident #1?s telephone order for Lantus was not signed by a physician within the required 14 days.

Plan of Correction: 1. Correction was done on 8/22/2019. Resident?s records reviewed by the Unit Managers and the resident #1?s telephone order was signed by the provider on 8/23/19.

2. A 100% audit of all current telephone orders will be conducted by the Administrator/designee to ensure a provider?s signature was received within 14 days of the verbal order. All findings will be corrected and reported to the QA Committee for continued improvement and analysis.

3. Nursing staff will be re-educated on the telephone ordering process by the Administrator/designee. When a telephone order is received, it will be faxed to the resident?s provider for signature by the nurse receiving the verbal order. A new process for tracking new orders will be implemented by the Unit Managers/designee where new orders are logged, verified by the following shift(s) until all required signatures are received.

4. Administrator/designee will screen 6 residents? telephone orders weekly for 8 weeks to ensure provider signatures are timely. All findings will be corrected and reported to the QA Committee for continued improvement and analysis.

Standard #: 22VAC40-73-680-D
Complaint related: No
Description: Based on record review and interview, the facility failed to ensure medications are administered in accordance with the physician's instructions.
Evidence:
1. Resident #1?s June 2019 Medication Administration Record (MAR) had staffs initials circled, documenting the resident did not receive Plaxix 75mg (Clopidogrel) 06-27-2019 through 06-30-2019; Amlodipine5mg 06-26-2019 through 06-30-2019; Ferrous Sulfate 325mg and Fluvoxamine 100mg 06-28-2019 through 06-30-2019; and Polyethylene Glycol 06-11-2019 through 06-30-2019. Documented on the back of the MAR as the reason the aforementioned medications were not administered was ?unavailable.?
2. On 08-19-2019, during resident #1?s record review with staff #1, the following signed physician?s prescriptions dated 06-10-2019 were observed ?Amlodipine (NORVASC) 5mg tablet- take 1 tablet (5mg total) by mouth daily; polyethylene glycol (PEG 3350) pack- take 1 packet (17 g total) by mouth daily; ferrous sulfate 325 (65 FE) MG tablet- take 1 tablet (325mg total) by mouth daily with breakfast; clopidogrel (PLAVIX) 75mg tablet- Take 1 tablet (75 mg tablet) by mouth daily; and fluvoxamine (LUVOX) 100mg capsule sustained-release 24 hr- Take 1 capsule (100mg total) by mouth daily.?
3. The ?Nurses Notes? dated 06-28-2019 documented resident #1 ??did not received Plavix 75mg Tab or Amlodipine meds this AM. Bottles were brought in by the wife but were not labeled correctly (Handwritten bottles). Resident also did not receive Ferrous Sulfate 325mg, fluxoxamine 100mg cap, or polyethylene glycol due to them not being available. Wife is aware of situation. Staff #1 made aware of situation and doctor has been notified??
4. During interview on 08-19-2019, staff #1 acknowledged resident #1?s aforementioned medications were not available, and acknowledged the facility did not administer the medications in accordance with the physician?s instructions.

Plan of Correction: 1. Correction was done on the day of the survey. The resident/representative, and the physician was informed of the missed medications administration. Medication error reports were completed by the Administrator/designee for the missed Clopidogrel, Amlodipine, Ferrous Sulfate, Fluvoxamine and Polyethylene Glycol for resident #1. Prior to the inspection, the facility had implemented corrective actions involving this resident that included clarification of involvement of wife, re-education to staff on the process for ordering medication from the pharmacy if not supplied by resident/representative within three days, as well as ongoing audits of MARs for documentation and of medication carts for sufficient supply of medication. An audit of resident #1?s MAR for the past three months was completed by the Administrator/designee and no other missed medications were identified.

2. After this incident and prior to this inspection, the Unit manager/designee completed a 100% audit of the current months of the Medications Administration Records (MARs) for missed as well as in house supply of medications for the residents who use outside pharmacies. Findings were corrected and communicated to the resident/representative and the physician.

3. All residents who utilize outside pharmacies were contacted by the Administrator/designee on the facility?s process of ordering from the contracted pharmacy if supplies are not received within three days of running out. Forms acknowledging the process were obtained from all affected residents by the Administrator/designee. This notice of intent to purchase medications from an outside pharmacy continues to be a part of the admission packet for all new residents and nursing staff were re-educated on the process by the Administrator/designee.

A weekly schedule for checking the medication supply was created by the Administrator and will be documented on the shift task report by the nurse/RMA working on the scheduled shift. The medication management plan was reviewed and updated by the Administrator along with other leaders in the company.

4. Administrator/designee will complete a weekly audit for 8 weeks of the shift task report to ensure weekly documentation of the medication supply check was done by the nurse/RMA. The Administrator/designee will audit six residents who use outside pharmacies per week for 8 weeks to ensure adequate supply is available. All findings will be corrected and reported to the QA Committee for continued improvement and analysis.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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