VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Emily Green Shores
500 Westmoreland Avenue
Portsmouth, VA 23707
(757) 399-3442

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Nov. 15, 2019 and Nov. 22, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced complaint inspection was completed by the Licensing Inspector from the Eastern Regional Licensing Office. The inspection was conducted on November 15, 2019 from 10:06 am until 4:39 pm, and on November 22, 2019 from 9:52 am until 2:32 pm. There were 24 residents in care. The complaint alleged concerns regarding lack of staff training with Foley Catheters, resident care, urine odor in resident rooms, resident falls, and the facility Administrator's schedule. During the inspection, a tour of the building was conducted with the Administrator. Resident records were reviewed, as well as staff training records. A review of staff schedules was conducted, as well as staff and resident interviews. The facility's fall protocol was reviewed with the Resident Care Coordinator and the Administrator. There was a discussion regarding reportable incidents and staff training. The facility does not have a written fall policy. Per the Administrator and Resident Care Coordinator, this policy will be developed. Also discussed the documentation requirements for private duty staff. The facility received violations in the area of Personnel; Admission, Retention and Discharge of Residents; and Resident care and Related Services. The areas of non-compliance were reviewed with the Administrator throughout the inspection and during the exit interview. Based on the information gathered the complaint was found to be valid due for the concern regarding staff training. 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. Your plan should include: 1. Step(s) to correct the non-compliance with the standard(s), 2. Methods to prevent re-occurrence, 3. Person(s) responsible for implementing each step and/or monitoring any preventive actions.

Violations:

Standard #:	22VAC40-73-210-E
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure staff receive training relevant to the population in care. Evidence: 1. During a tour with staff #1, resident #1 was observed with a Foley Catheter. During discussion, staff #1 stated that resident #3 has a Foley Catheter also. 2. Staff training records were reviewed. No documentation of Foley Catheter training was observed. 3. Staff #1 acknowledged the facility did not have training relevant to specifically, residents with Foley Catheters.
Plan of Correction:	The Resident Care Coordinator will schedule an in-service for all Direct Care and Medication Aide on Foley Cather Care when a resident is admitted, has a new order, or when there is a new hire in Nursing. When the facility has a resident with a Foley Cather, The Administrative Assistant will check training records and review with the Resident Care Coordinator once a month to ensure continuity and communication between Nursing and Administration.
Standard #:	22VAC40-73-220-B
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure private duty staff who are not employees of a licensed home care organization who provide direct care to residents of an assisted living facility are qualified for the types of direct care they are responsible for providing to residents and maintain documentation of the qualifications. Evidence: 1. During review of resident #6?s record, nursing notes dated 9-3-19 documented that the resident was sent out to the hospital due to complaints of hip pain. The nursing note also documented the resident's private duty aide reported on 9-3-19 that the resident had a fall in the shower the day before (9-2-19) while the aide was providing assistance with bathing. 2. Review of resident #6?s Uniform Assessment Instrument (UAI) dated 10-10-18 indicated the resident needs ?Human Help/ Physical Assistance? with bathing dressing, and transferring. Resident #6?s Individualized Service Plan (ISP) dated 10-10-18 indicated the resident needs supervision with bathing and physical assistance with dressing from a sitter/personal care aide (private duty #1). 3. During interview, staff #1 acknowledged resident #6 had a private duty aide since admission on 5-28-14 and that the private duty aide provided direct care to the resident to include physical assistance with bathing, dressing, and transferring. 4. Review of private duty aide #1?s record revealed the facility did not have documentation of the private duty aide?s qualification to provide direct care to resident #6. 5. Staff #1 acknowledged the missing documentation of the private duty aide's qualifications.
Plan of Correction:	Administrator will ensure that private duty staff working with residents and assisting with activities of daily living will have documented proof of adequate training. A minimum certification of PCA will be accepted. The Administrative Assistant will maintain a private duty tickler and Administrator will check tickler monthly.
Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure the fall risk rating was reviewed and updated after a fall. Evidence: 1. The following was observed in resident #1's record: a. The resident was found on the floor in her room on 4-8-19 and b. Resident was found on the side of the driveway on 8-7-19. c. Resident #1's record did not contain an updated fall risk rating completed after each fall. 2. The following was observed in resident #3's record: a. Resident #3 had a fall on 10-11-19. Per the resident's nursing notes, the resident fell from the toilet seat and went out to the emergency room. b. Resident #3's record did not contain an updated fall risk rating completed after the fall on 10-11-19. 3. During interview staff #1 and staff #2 acknowledged the fall risk risk rating was not completed for residents #1 and #3.
Plan of Correction:	Upon admission of a resident, after a resident fall and when there is a change of the resident's assisted living level, the Administrator or Resident Care Coordinator will complete a fall risk assessment and will have the Resident care Coordinator add the fall risk to the resident's ISP.
Standard #:	22VAC40-73-325-C
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure that after a resident falls, an analysis of the circumstances of a fall and interventions that were initiated to prevent or reduce risk of subsequent falls was completed. Evidence: 1. Resident #1's record documented the following falls in the nursing notes: a. On 5-9-19 the resident was found on the floor in her room with a subsequent fall in her room on 5-22-19. b. On 10-7-19 the resident was found on the floor in the back hall. The 24 hour shift report documented resident #1 had a subsequent fall on the 11 pm-7 am shift on 10-12-19/10-13-19. 2. The record did not contain documentation of an analysis of the circumstances of the falls and intervention to prevent the subsequent falls on 5-22-19 and 10-12-19. 3. Staff #1 and staff #2 acknowledged that an analysis of the resident's falls was not completed.
Plan of Correction:	The Resident Care Coordinator will develop a fall log. All falls will be documented on an incident report and the incident report will be reviewed by the Administrator within 48 hours. The Administrator will document on the incident report the interventions determined to reduce the risk of a subsequent fall. These interventions will be documented on the ISP by the Resident Care Coordinator. The Administrator will examine the ISP to ensure the interventions in place to reduce the risk of falls are there.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on observation, record review, and interview, the facility failed to ensure the Individualized Service Plan (ISP) include a description of the resident?s identified needs. Evidence: 1. On 11-15-19 during a tour with staff #1, resident #1 was observed to have a Foley Catheter. 2. Resident #1?s ISP dated 10-11-19 did not include a description of the resident?s need for a Foley Catheter, a description of what services will be provided and who will provide the services to address the resident?s need for a Catheter. 4. Staff #1 and staff #2 acknowledged resident #3?s ISP did not include the resident?s need for a Foley Catheter.
Plan of Correction:	The Resident Care Coordinator will document the need for a Foley Cather on the resident's ISP. Also documented on the ISP and the Foley Cather will be emptied on every shift and when needed, as needed by the RMA and Direct Care staff. The Administrator will review the ISP of all residents with Foley Cather monthly.
Standard #:	22VAC40-73-650-E
Complaint related:	No
Description:	Based on record review and interview, the facility did not ensure the physician?s or other prescriber?s orders were maintained in the resident?s record. Evidence: 1. Resident #3 was admitted on 9-30-19. Resident #3?s initial Uniform Assessment Instrument (UAI) dated 8-20-19 indicated the resident had a Foley Catheter. 2. Resident #3's record did not have an order for the Foley Catheter upon admission nor on 11-22-19 at the time of inspection. 3. Staff #1 and staff #2 stated resident #3 was admitted with the Foley Catheter and still currently has the Foley Catheter in place. Staff #1 and staff #2 acknowledged the resident did not have a physician?s order on file for the Foley Catheter.
Plan of Correction:	The Resident Care Coordinator will determine if a resident has an order for a Foely Cather upon admission, upon return from a skilled nursing facility, and upon return from hospital. The Resident Care Coordinator will attempt to obtain an order if such an order is not presented wit the documentation accompanying the resident upon return.
Standard #:	22VAC40-73-650-F
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure whenever a resident is admitted to a hospital for treatment of any condition, the resident?s primary physician is made aware of all medication orders and treatments prior to or at the time of the resident?s return to the facility and document the contact with the physician. Evidence: 1. Resident #1?s hospital history and physical documented the resident was admitted to the hospital on 10-2-19 for shortness of breath, sepsis and urinary tract infection (UTI). Resident #1?s hospital discharge summary documented the resident was discharged and returned to the facility on 10-11-19 with the following medication changes: Guaifenesin 600mg 1 tab two times per day as needed, docusate sodium 100mg 1 two times per day PRN. The resident was placed on hospice and the following medications were added: Lorazepam 2mg/ml replaced Ativan 0.5mg, Hydromorphone 1mg/ml, Naloxegol 12.5mg, ondansetron 4mg, Polyethylene glycol 17 gram as needed, Scopolamine 1mg, and Simethicone 80mg. 2. Resident?s record did not contain documentation of contact to the resident?s primary physician to make the physician aware of the medication changes and hospice care. 3. Staff #2 acknowledged resident #1?s primary physician was not contacted prior to or at the time of return to the facility.
Plan of Correction:	The Resident Care Coordinator will ensure that when a resident returns to the facility from the hospital or a skilled nursing facility, an order for Hospice has been placed in the resident's chart and that the Resident Care Coordinator will inform the doctor within 48 hours of any changes or new orders and will report to the Administrator. The Administrator will check for medication changes on the MARs weekly. The Administrator will check for Hospice orders upon resident's return to the facility.
Standard #:	22VAC40-73-700-2
Complaint related:	No
Description:	Based on observation and interview, the facility failed to post ?No Smoking-Oxygen in Use? sign in a room where oxygen was in use. Evidence: 1. On 11-15-19 during a tour with staff #1, resident #1 was observed in her room with an oxygen concentrator in use. The resident?s room door nor entrance did not have a sign posted indicating oxygen was in use. 2. Staff #1 acknowledged the ?No Smoking-Oxygen in Use? sign was not posted in resident #1?s room door nor entrance.
Plan of Correction:	The Resident Care Coordinator will ensure that the Environmental Service Director post a "no smoking oxygen in use" sign outside of the residents' room where oxygen is in use. The Environmental Service Director will report to the Resident Care Coordinator once the sign has been posted.