VIRGINIA DEPARTMENT OF SOCIAL SERVICES

COMMONWEALTH SENIOR LIVING AT HAMPTON
1030 TOPPING LANE
Hampton, VA 23666
(757) 826-3728

Current Inspector: Darunda Flint (757) 807-9731

Inspection Date: Sept. 25, 2019 and Oct. 15, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced focused monitoring inspection was conducted by two Licensing Inspectors from the Eastern Regional Office on 09-25-2019 from 9:27 AM to 2:11 PM and on 10-15-2019 from 10:53 AM to 3:14 PM. There were 85 residents in care at the time of the inspection. A medication pass observation was conducted on the Assisted Living Unit and the Special Care Unit. 3 resident records, 2 staff records, staff schedules, and time sheets were reviewed. Interviews were conducted. The areas of non-compliance were discussed with the Administrator throughout the inspection and during the exit interview. The facility received violations "under" Resident Care and Related Services. 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, 11-14-2019.

Violations:

Standard #:	22VAC40-73-550-C
Description:	Based on observation, record review, and interview, the facility failed to ensure any resident of an assisted living facility has the rights and responsibilities as provided in ? 63.2-1808 of the Code of Virginia and this chapter to include the right to be treated with courtesy, respect, sensitivity, and dignity. Evidence: 1. On 09-30-2019, staff #1 e-mailed a final incident report dated 09-27-2019 involving resident #1. The ?Type of Incident? documented was ?Allegation of Resident Rights Violation.? The incident report documented ?Resident reported that [the resident] refused brief changing and staff forcibly changed [the resident] while holding hands. During investigation it was discovered that resident?s brief was wet and resident became combative while staff attempted to change. Staff stated that resident informed them [the resident] didn?t want to be changed as the resident yelled and hit at them. Staff members proceeded to comfort [the resident] while holding [the residents] hand and continuing to remove the wet brief.? The documented date and time of the incident was 9-24-19 at 5:30am, and the names of the witnesses involved in the incident were staff #2 and staff #3. The incident report also documented ?staff were given corrective action for violation of resident right?? Staff #1 indicated staff #2 and staff #3 received the corrective action due to violation of resident right. 2. On 10-15-2019, staff #1 provided staff #2?s typed statement dated 09-25-2019, documenting ?Staff #2 was aware that resident #1 did not want to be checked every two hours? Staff #2 entered the room between 5:30 and 6am and asked if [the resident] needed to be changed? Staff #2 said to resident #1 ?You?re soaked.? Resident #1 said, ?I don?t need to be changed; I prefer for 7am-3pm shift to do it because I want to be washed up.? Staff #2 said ?This is my last round to check you so I?m just going to change you?? Staff #2 went to get staff #3? both walked into the room and told [the resident] that they were about to change [the resident] and resident #1 began to fight. Staff #3 was holding resident #1?s hands and trying to prevent resident #1 from hitting staff #2 as she removed the brief sides, slid it off, and put the other one on [the resident].? 3. Staff #2 did not treat resident #1 with courtesy, dignity, or respect. The resident stated to staff #2 ?I don?t need to be changed; I prefer for 7am-3pm shift to do it because I want to be washed up.? Staff #2 replied, ?This is my last round to check you so I?m just going to change you.? There was no documentation of staff #2 washing the resident prior to applying the new brief. Additionally, staff #2 did not honor resident #1?s wishes. 4. Staff #2 and staff #3 did not treat resident #1 with sensitivity or dignity. On 09-25-2019, a sign was observed posted on resident #1?s wall which documented ?Under no circumstances is a male staff member allowed to attend to resident #1.? Staff #3, a male Registered Medication Aide, held resident #1?s hands while staff #2 removed the resident?s brief. 5. On 10-15-2019 during staff record review with staff #1, staff #2 and staff #3 received a ?Counseling/Disciplinary Notice? dated 09-27-2019 for ?Violation of failing to follow resident rights policy and procedures for an aggressive resident.? 6. During interview on 10-15-2019, staff #1 indicated he was aware of the aforementioned sign posted in resident #1?s room and stated that the resident ?does not want a male seeing her vagina.? When asked what staff is supposed to do when a resident is refusing to be changed or is becoming aggressive, staff #5 stated, ?the staff is supposed to re-approach the resident, get another caregiver to assist, or come back at a later time.? Staff #5 also stated ?It is the resident?s right to refuse.?
Plan of Correction:	Employees were suspended pending investigation. Investigation was completed, employees were given counseling on resident rights, all staff reeducated on resident rights. Resident #1 ISP was updated to included caretaker preference and behavioral expressions. Community will continue to screen applicants to include reference checks, credential verification, background checks, sworn disclosure, and other elements to hire and retain associates to provide for the health, safety, and well-being of all residents in accordance with DSS Licensing. Those found not to meet the requirements will not be hired nor retained. Those found to violate care expectations will be addressed by means of disciplinary action and mandated reporting to APS and the appropriate credentialing board. Associates are provided resident rights education at time of hire, annually, and as needed. Executive Director, Resident Care Director, or designee will continue to monitor care provided and screen and retain high performance associates to ensure continued compliance.
Standard #:	22VAC40-73-650-A
Description:	Based on record review and interview, the facility failed to ensure no treatment is started without a valid order from a physician. Evidence: 1. On 09-25-2019 and 10-15-2019, during resident #2?s record review with staff #1, the facility initiated finger stick blood sugar checks without a valid order from a physician. Resident #2 admitted to the facility on 07-01-2019. The ?Admission Orders? signed and dated by the physician on 06-27-2019, documented ?All medications crushed- See attachment;? however, there was no additional documentation attached to the ?Admission Orders.? In addition, there were no physician?s orders on file for blood sugar checks until 08-03-2019. Resident #2?s July 2019 Medication Administration Record documented staff administered finger stick blood sugar checks from 07-05-2019 through 08-02-2019. 2. During interview on 09-25-2019 and 10-15-2019, staff #1 acknowledged the facility started resident #2?s finger stick blood sugar checks without a valid order from a physician; and the resident received the blood sugar checks from 07-05-2019 to 08-02-2019.
Plan of Correction:	Order was obtained from the prescriber for Resident #2. All nurses and RMAS were re- . inserviced on the importance of ensuring that no medications are started or changed by the community without a valid order from a prescriber. All medication administration orders were checked to ensure that a valid physicians order was present to ensure compliance. Licensed Nurse will continue to review all new medication orders in the Electronic Medication Administration Record and compare them to the physician's order and diagnosis prior to approving medication for administration to ensure ongoing compliance. Resident Care Director, Assistant Resident Care Director, or designee will complete monthly cart and chart audits and weekly med pass audit to ensure no medication is started without a valid order from a prescriber to ensure ongoing compliance with administration of medications and documentation.
Standard #:	22VAC40-73-680-D
Description:	Based on observation, record review, and interview, the facility failed to ensure medications are administered in accordance with the physician?s or prescriber?s instructions. Evidence: 1. On 09-25-2019, during the medication pass observation at approximately 10:58 AM, staff #4 was observed administering 1 tab of Aspirin 325mg to resident #3. 2. On 09-25-2019 and 10-15-2019, during record review with staff #1 and staff #5, resident #3 admitted to the facility on 03-08-2019. The ?Admission Orders? signed and dated by the Nurse Practitioner on 03-07-2019, documented ?Aspirin 324mg once daily PO-dx Anti-thrombotic.? The March, April, and September 2019 Medication Administration Records documented ?Aspirin 325mg? had been administered to resident #3. Staff #1 and staff #5 could not locate and/or provide documentation on file of a change in the physician?s or prescriber?s order for Aspirin 325mg. There was no documentation of the Aspirin 324mg being administered to resident #3 as ordered. 3. On 09-25-2019, during interview, staff #5 stated ?Aspirin 234mg does not exist.? 4. During interview on 10-15-2019, staff #1 acknowledged resident #3 was receiving Aspirin 325mg and did not receive the Aspirin 324mg in accordance with the prescriber?s instructions.
Plan of Correction:	Corrected order was obtained from the prescriber for Resident #3. All nurses and RMAS were re-inserviced on the importance of ensuring that medications administered are in accordance with prescriber written order. All medication administration orders were checked to ensure that a valid physicians order was present to ensure compliance. Licensed Nurse will continue to review all new medication orders in the Electronic Medication Administration Record and compare them to the physician's order and diagnosis prior to approving medication for administration to ensure ongoing compliance, Resident Care Director, Assistant Resident Care Director, or designee will complete monthly cart and chart audits and weekly med pass audit to ensure no medication is started without a valid order from a prescriber to ensure ongoing compliance with administration of medications and documentation.