VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bickford of Suffolk
6860 Harbour View Boulevard
Suffolk, VA 23435
(757) 215-0058

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Oct. 1, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

An unannounced complaint inspection was conducted by three (3) Licensing Inspectors from the Eastern Regional Office. The inspection was conducted on October 1, 2019 from 10:12 am until 4:36 pm. There were 59 residents in care. The complaint alleged concerns regarding resident care, staff job duties to include pet care, expired medications, medication carts, and overstock of medications stored at facility. During the inspection, a tour of the building and grounds was conducted, a check of medication carts and medication storage areas was conducted in the memory care unit and on the assisted living side. Resident records were reviewed. During the inspection there was discussion regarding signatures on medication orders from hospice providers, also discussed being mindful of ordinary materials in the memory care unit that may be a danger to residents. Discussed expiration dates on medications per pharmacy packaging, and staff job duties and responsibilities. Based on the information gathered during this inspection, the complaint was found to be valid due to concerns made regarding pet care and medication carts. The facility received violations in the areas of Personnel, Resident Care and Related Services, and Buildings and Grounds. The areas of noncompliance were discussed with the Administrator throughout the inspection and during the exit interview. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice. The plan of correction must indicate how the violation will be or has been corrected. The plan of correction should include: 1. Step(s) to correct the non-compliance with the standard(s), 2. Measures to prevent re-occurrence, and 3. Person(s) responsible for implementing each step and/or monitoring any preventive action.

Violations:

Standard #:	22VAC40-73-120-B
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure all staff were oriented on the specific duties and responsibilities of their positions. Evidence: 1.Licensing received a complaint that alleged staff have to ?take out and feed residents pets?. During a review of the facility?s Initial Orientation Checklist for staff, the Certified Nursing Assistant (CNA) job description, and the CMA/QMA/CMT/MA/RMA job description, the documents did not indicate that the staff are responsible for caring for resident pets. The Orientation Checklist does not include information regarding pet care or a section that indicates staff were oriented to their duties regarding pet care. 2.Review of resident #1?s Resident Agreement indicates the facility will provide pet care as listed under ?Other Services?. 3.During interview, staff #1 acknowledged resident pet care is included in the Resident Agreement and is a part of the duties and responsibilities of facility staff. Staff #1 also acknowledged the staff orientation and job descriptions did not detail specific duties and responsibilities for resident pet care to verify that staff were oriented to these specific job duties.
Plan of Correction:	The insufficiency will be corrected as follows: ? Ed reached out to HR at corporate office to add Pet Care into the Job Description. The following measures will be taken to ensure the problem does not occur again: ? CNAs and RMAs job description has included Pet Care Services. Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? ED
Standard #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure the Uniform Assessment Instrument (UAI) was completed at least annually. Evidence: 1. Resident #6 admitted on 11-10-17. Resident #6?s most current UAI in the record was 11-06-17. 2. Staff #2 acknowledged the UAI in the record was the most current and was not updated at least annually.
Plan of Correction:	The insufficiency will be corrected as follows: ? Resident #6 no longer resides at Bickford. Left on 10/10/19. The following measures will be taken to ensure the problem does not occur again: ? Nurse Coordinators will ensure UAI?s are completed at least annually and when there is a change in condition. ? Ed will perform 6 random weekly UAIs for the next 10 weeks to ensure UA was completed at least annually. Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? ED/Nurse Coordinators
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on observation, record review, and interview, the facility failed to ensure Individualized Service Plans (ISPs) were reviewed and updated as needed as the condition of the resident changes. Evidence: 1. During tour of the facility, oxygen was observed in resident #7?s room. 2. During review of resident #7's record, the resident received a hospice order for Oxygen 2LPM via nasal cannula as needed on 04-26-19. Resident #7?s most current ISP dated 06-12-19 did not document the resident?s need for oxygen. 3. Staff #2 acknowledged resident #7 had an oxygen order and the resident?s ISP did not include an update documenting oxygen use.
Plan of Correction:	The insufficiency will be corrected as follows: ? Resident #7 ISP has been updated to reflect the oxygen usage. An addendum was completed on 10/25/19. The following measures will be taken to ensure the problem does not occur again: ? Nurse Coordinator will audit all residents ISPs that are using Oxygen to ensure ISPs are reviewed and updated as needed in the condition of resident oxygen changes. ? ED will perform 2 random audits of residents ISPs with oxygen orders to ensure oxygen is documented appropriately in ISP. Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? ED/Nurse Coordinators
Standard #:	22VAC40-73-650-A
Complaint related:	No
Description:	Based on observation, record review, and interview, the facility failed to ensure no treatment was discontinued by the facility without a valid order from a physician or other prescriber. Evidence: 1. Resident #7?s record contained a physician?s order dated 07-03-19 for a Foley catheter that documented: ?Insert 16F foley catheter ? [home health/hospice company] to change q30 days, dx- urinary retention.? 2. Resident #7?s physician?s orders dated 09-03-19 under treatments documented: ?Empty foley catheter qshift. And provide pericare daily and prn.? 3. According to staff #2, resident #7 no longer uses a Foley catheter. Additionally, a Foley catheter was not observed on resident #7 during a tour of the facility. The resident?s record did not contain an order to discontinue the catheter. 4. Staff #2 acknowledged the resident?s order for a Foley catheter, and that there was no order to discontinue treatment from a physician or other prescriber.
Plan of Correction:	The insufficiency will be corrected as follows: ? Resident #7 Hospice Company has been contacted to notify of missing order to discontinue catheter from a physician or prescriber. ? Hospice company provided a written order for the discontinuation order on 10/01/19. The following measures will be taken to ensure the problem does not occur again: ? Nurse Coordinators will audit all residents who are currently using a catheter to ensure catheter orders are correct. ? Director will perform an audit on 2 random residents? charts that are currently using catheters to ensure orders are correct. Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? ED/Nurse Coordinators
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. During resident #3?s record review with staff #2, a hospice physician's oral order dated 08-26-2019 for Robitussin DM 10ml and a hospice physician?s oral order dated 08-30-2019 to change Lasix dose from 20mg to 40mg did not contain a signature from the physician and was not signed within the required 14 days. 2. During interview, staff #2 acknowledged that resident #3? aforementioned hospice physician?s oral orders were not signed by the physician within the required 14 days.
Plan of Correction:	The insufficiency will be corrected as follows: ? Resident #3 Hospice company has corrected all orders on 10/01/19. ? Nurse Coordinators met with Heartland Hospice and their MD to discuss expectations and communications on 10/18/19. The following measures will be taken to ensure the problem does not occur again: ? Nurse Coordinator will ensure resident?s hospice physicians orders will be signed when the orders are given. ? Nurse Coordinator will audit all residents that are currently on hospice to ensure orders are signed by physician. ? Ed will perform 3 random audits of resident?s hospice orders to ensure orders are signed by the physician. Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? ED/Nurse Coordinators
Standard #:	22VAC40-73-680-B
Complaint related:	Yes
Description:	Based on observation and interview, the facility failed to ensure medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. Evidence: 1.During a spot check of the medication cart on the Assisted Living Unit with the medication tech and staff #1, one (1) brown round pill labeled 44921 was observed at the bottom of the drawer and was not in the pharmacy issued container with the prescription label or direction label attached. 2.In the memory care unit with staff #2, one (1) robust dark brown oval shaped pill was observed at the bottom of the top drawer and was not in the pharmacy issued container with the prescription label or direction label attached. 3.Staff #1 and staff #2 acknowledged the loose pills observed.
Plan of Correction:	The insufficiency will be corrected as follows: ? Both Memory Care and Assisted Living Med Carts have been audited to ensure no pills are loose 10/01/19. The following measures will be taken to ensure the problem does not occur again: ? Nurse Coordinators will audit the both med carts weekly to ensure medications remain in the pharmacy issued container, with the prescriptions label or direction label attached. Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? Nurse Coordinators
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure medications were administered in accordance with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. According to the current Virginia Board of Nursing registered medication aide curriculum ?18VAC90-60-110. Standards of practice. A medication aide shall not: Administer by intramuscular or intravenous routes?. 2.On 10-1-19 during review of resident #1?s August 2019 Medication Administration Record (MAR), the MAR documented that on 8-14-19 staff #4 administered Cyanocobalam 1000MCG 1ML injection intramuscularly to resident #1. 3.During interview, staff #1, staff #2 and staff #3 acknowledged that staff #4 was a medication aide (RMA) and was not qualified to administer the injection intramuscularly. Staff #3 is an LPN an indicated that she administered the injection. However, there was no documentation on the MAR to indicate the injection was administered by staff #3. Staff #3 was not able to provide any other documentation to verify that she administered the injection.
Plan of Correction:	The insufficiency will be corrected as follows: ? The shot was d/cd on 09/30/19. The following measures will be taken to ensure the problem does not occur again: ? Nurse Coordinators will perform frequent medication observation passes on all med aides. ? Any intramuscular or intravenous routes will only be administered by a Nurse. Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? Nurse Coordinators
Standard #:	22VAC40-73-680-E
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure medical treatments ordered by a physician are provided according to his instructions and documented. The documentation should be maintained in the resident's record. Evidence: 1. During resident #3?s record review with staff #2, a physician?s order dated 08-28-2019 to ?Increase O2 to 5L continuous via NC @ this time? was observed. The August and September 2019 Treatment Administration Record (TAR) documented ?O2- place on QHS at 2L via Nc. Remove in the AM final round.? The TAR?s did not document that the resident was receiving 5L of oxygen continuously. In addition, staff #2 could not locate and/or provide documentation on file verifying the staff administered 5L of continuous O2 to resident #3. 2. During interview, staff #2 acknowledged the facility did not provide resident #3 oxygen in accordance with the physician?s instructions.
Plan of Correction:	The insufficiency will be corrected as follows: ? Resident #3 is now on the correct oxygen treatment in accordance with physician?s order. ? Nurse coordinators met with Resident #3 Hospice Company and their MD on 10/18/19 to discuss the importance of communication between the facility and hospice to ensure residents treatments and orders are followed. The following measures will be taken to ensure the problem does not occur again: ? Nurse Coordinators will audit all resident charts that are receiving oxygen to ensure oxygen orders are being followed thoroughly. ? ED will perform 2 random audits of residents with oxygen orders to ensure oxygen orders are being followed thoroughly. Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? ED/Nurse Coordinators
Standard #:	22VAC40-73-860-I
Complaint related:	No
Description:	Based on observation and interview, the facility failed to store cleaning supplies in a locked area. Evidence: 1.During a tour of the memory care unit with staff #1, unlocked cleaning supplies were observed in resident #2?s bathroom, to include one 19 oz. bottle of disinfectant spray and one bottle of Fabreze air freshener spray. 2.Resident #2 has a serious cognitive impairment, as documented on the Serious Cognitive Assessment form dated 9-7-17 and the most recent Review of Appropriateness for Continued Residence in the Special Care Unit dated 6-11-19. 3.During interview, staff #1 acknowledged the unlocked cleaning supplies in resident #2?s bathroom.
Plan of Correction:	The insufficiency will be corrected as follows: ? All cleaning supplies are removed from residents? apartments and are now stored properly in safe and locked designated areas in the memory care on 10/02/19. The following measures will be taken to ensure the problem does not occur again: ? Nurse Coordinators will perform weekly walk through in Memory Care to ensure cleaning supplies are stored properly in safe and locked designated areas. ? ED will perform weekly walk through in Memory Care for the next 6 weeks to ensure cleaning supplies are stored in safe and locked designated areas. Person(s) responsible to implement and monitor corrective measure to ensure compliance: ? ED/Nurse Coordinators