VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hughes Home
100 Caroline Street
Fredericksburg, VA 22401-6104
(540) 373-4100

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Nov. 14, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Date of Inspection: November 14, 2019 Type of Inspection: Complaint inspection Standards Investigated: Medication administration Complaint was determined valid If you have any questions, please do not hesitate to contact me at ken.koontz@dss.virginia.gov If you need a copy of any of the DSS Model forms or to review any inspection, you can find the information on the internet: www.dss.virginia.gov The Designated Charge Staff and the Licensing Inspector discussed the risk assessment ratings for the violations for this inspection.

Violations:

Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on interviews and chart review as part of a complaint inspection, it was determined the facility did not ensure all medications were 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: Resident A was admitted to the facility on 9/13/2019. The resident had an order for Ativan twice a day for BPSD and every eight hours as needed for anxiety, Depakote two times a day for BPSD, Donepezil one time a day for dementia, Gabapentin 3 times a day for back pain, Lisinopril one time a day for HTN, Memantine two times a day for dementia, Simvastatin one time a day for hypercholesterol, Tylenol every 8 hours as needed for pain and Vitamin D daily. An error with faxing the orders to the pharmacy resulted in the resident only receiving the Vitamin D. Resident A bit a resident on 9/16/19 then threatened to kill a resident the following day. This resulted in the police transporting the resident, against her will, to the Emergency Department. The ED contacted the facility later for the resident to return, and the facility refused her return.
Plan of Correction:	Facility has hired a nurse who is now responsible for oversight including reviewing admissions and ensuring paperwork is completed. Facility has updated New Resident Check Sheet to include confirming EMAR and Physical matches.