VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Leigh Hall
890 Poplar Hall Drive
Norfolk, VA 23502
(757) 461-5956

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Sept. 16, 2019 and Oct. 24, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced complaint inspection regarding resident care and infection control was conducted by two Licensing Representatives on September 16, 2019 from 10:59 a.m. to 4:50 p.m. and October 24, 2019 from 9:09 a.m. to 2:32 p.m. There were 73 residents in care. The following was discussed during the inspection: residents? personal data, hoyer lifts, and home health documentation. Please submit your ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it within 10 calendar days. The plan of correction must indicate how the violation will be or has been corrected. The plan of correction must include: 1. Step(s) to correct the noncompliance with the standard(s) 2. Measures to prevent reoccurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventative measures. If you have any questions, please contact your inspector Alexandra Poulter at 757-613-5133 or alexandra.poulter@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-450-F
Complaint related:	Yes
Description:	Based on 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 changed. Evidence: 1. Resident #1?s most current ISP dated 06-06-19 did not document physical therapy services were being provided. 2. Physical therapy documentation dated 08-14-19 on ?Outside Agency Documentation? form documented, ?Evaluated for balance, gait, + strength issues related to recent falls. See 3x/wk?. Subsequently, documentation dated 09-11-19 on ?Outside Agency Documentation? form document, ?Gait training, Balance + coordination work.? 3. Per interview with resident #1, physical therapy services were still occurring as of 09-16-19. 4. Staff #1 observed and confirmed physical therapy services were not documented on resident #1?s ISP.
Plan of Correction:	The ISP of resident #1 was updated on 10/24/2019 to accurately reflect changes. All other resident ISPs were checked to ensure accuracy. Resident Care Director or designee will randomly audit 3 ISPS per month for 6 months of resident's who are on outside services to assure accuracy of services and compliance.
Standard #:	22VAC40-73-450-H
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure that the care and services specified in the individualized service plan (ISP) were provided to the resident. Evidence: 1. During record review on 09-16-19 and 10-24-19, resident #2?s most current ISP dated 09-07-19 identified ?Needs and Services? for ?SN- Home Health Services on 08-31-19 occurring twice weekly, and Home Health will communicate with community staff any change in resident?s condition and changes in resident?s plan of care. Left Anke ? Cleanse with dermal wound cleanser, apply puachol to wound bed and cover with foam border dressing.? 2. Resident #2?s physician?s order dated 08-29-19 documented ?[Provider?s name] home health to evaluate and treat wound to L ankle?. 3. Requested staff #1 provide documentation of home health notes documenting care was provided to resident #2. Staff #1 did not produce documentation that services were provided. 4. Staff #1 and staff #2 observed and confirmed no home health notes documenting care and services provided were contained in resident #2?s record.
Plan of Correction:	Resident Care director has reached out to resident #2's outside agency to obtain documentation of care. Executive Director, Resident Care Director, and Assistant Resident Care Director will meet with representatives from all outside agencies who visit and document on our residents to review policies and expectations of outside agency documentation. Resident Care Director or designee will audit files of residents receiving services from outside agency monthly to ensure documentation is present.
Standard #:	22VAC40-73-650-C
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure physician?s or other prescriber?s oral orders were reviewed and signed by a physician or other prescriber within 14 days. Evidence: 1. On 09-16-2019 during resident record review with staff #1, the following physician?s or other prescriber?s oral orders were not reviewed and signed by a physician within 14 days: A. Resident #3?s order dated 04-02-19 for ?Zaroxolyn 5 mg PO x 7 days for edema; chest x-ray for cough, edema, possible pneumonia?; and B. Resident #4?s order dated 07-11-2019 for ?Flagyll 500mg 1 tab to be crushed and sprinkled onto sacral wound bed Qd x7days for possible infection;? order dated 07-24-2019 for ?Flagyll 500mg 1 tab to be crushed and sprinkled onto sacral wound bed QD;? and order dated 07-10-2019 to ?D/C current tx order to all sacral and buttocks wounds?.?. 2. Staff #1 observed and confirmed the physician or other prescriber?s order were not signed for Resident #3 and Resident #4?s orders.
Plan of Correction:	Orders for resident #3 and #4 have been updated to include Physician's signatures. All other resident records were audited to ensure compliance. Executive Director, Resident Care Director, and Assistant Resident Care Director will meet with Leigh Hall's Physician and review policy regarding signing orders. Resident Care Director or designee will physician orders monthly to ensure ongoing compliance.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure medications were administered to residents in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. On 10-14-2019 during review of resident #4?s December 2018, January 2019, May 2019, and June 2019 Medication Administration Records (MAR) with staff #1, Calazime with Olivamine 3.5%-0.2% paste was not documented. The physician?s order dated 12-11-2018 documented ?Remedy Calazime with Olivamine 3.5%-0.2% paste- Apply topically to bottom every 2 hours as needed for skin barrier?. Additionally, the ?Progress Note? from the physician dated 05-17-2019 and 06-14-2019 documented ?calazime with olivamine paste applied to bottom every 2 hours as needed?. 2. Staff #1 could not locate a discontinued order for the Calazime with Olivamine 3.5%-0.2% paste and could not verify that the paste was administered to the resident as instructed by the physician. Additionally, resident #4?s record did not contain documentation of the physician being made aware of the Calazime with Olivamine not being applied as instructed. 3. Upon further review of resident #4?s record with staff #1, ?Narrative Charting? notes dated 06-10-19 documented ?It was brought to my attention on 6-4-19 that the resident has skin breakdown to [the residents] coccyx.? 4. During interview on 10-14-2019, staff #1 confirmed the facility did not administer the Calazime with Olivamine 3.5%-0.2% paste to resident #4 as needed for skin barrier and acknowledged that the paste was not on the aforementioned MAR?s. Additionally, staff #1 acknowledged resident #4 had skin breakdown to the coccyx area in June 2019.
Plan of Correction:	Resident is no longer at the community. Resident Care Director and Assistant Resident Care Director will continue with auditing 5 random resident MARs monthly along with verifying medications on admission orders. Going forward with all new admissions Resident Care Director and or designee will document and review with attending Physician at resident's time of admission and for a second time 7 days after admission assuring the accuracy of the resident's admission orders versus what is on the MAR to assure the medications match the admission orders.