VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Ashby Ponds, Inc.
21160 Maple Branch Terrace
Ashburn, VA 20147
(571) 291-6210

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Nov. 26, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

On 11/26/19 Licensing Inspector (LI) conducted unannounced inspection in response to self-reported incidents. Reviewed resident records and conducted resident and staff interviews. Possible violations were discussed at the exit interview.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based upon a review of records and interviews with staff, the facility failed to ensure that medications shall be 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 #5 has a physician's order for Oxycodone 5mg to be given at 8:00 am, 4:00 pm, and 10:00 pm. According to the controlled medication utilization record and interview with staff, Resident #5 did not receive the 10:00 pm dose of Oxycodone on November 5th, 14th, 15th, 22nd, and 23rd of 2019.
Plan of Correction:	A 100% audit of all narcotic medication administration records will be completed by 12/26/2019 to ensure that medications are administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice. Wellness Manager or designee will ensure completion of monthly audit of narcotic medication administration for 10 residents for 3 months beginning 1/10/2020 to ensure that medications are administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice. Staff Development Coordinator or designee will ensure that 100% of the Registered Medication Aides are educated on the Medication Administration Policy and Procedure by 12/26/2019.