VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bickford of Virginia Beach
2629 Princess Anne Road
Virginia beach, VA 23456
(757) 821-0198

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: Nov. 22, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

An unannounced focused monitoring inspection was conducted by the Licensing Inspector from the Eastern Regional Office on 11/22/2019 from 8:27 AM to 10:41 AM. The inspection was regarding a resident elopement on the special care unit. There were 20 residents in care at the time of the inspection. A tour of the special care unit was conducted and windows and doors were observed. 1 resident record, staff schedules, and time sheets were reviewed. The following was discussed with the Divisional Director of Operations and Administrator: date of the physical examination, prohibitive conditions, documentation for placement on the special care unit, wandering behaviors, 2 hour checks, staffing on the special care unit, and private duty services. The areas of non compliance were discussed with throughout the inspection. The facility received violations "under" Personnel, Admission, Retention, and Discharge of Residents, Resident Care and Related Services, and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. 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, 12-22-2019.

Violations:

Standard #:	22VAC40-73-1110-A
Description:	Based on record review and interview, prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee should determine whether placement in the special care unit is appropriate. The determination and justification for the decision should be in writing and be retained in the resident's file. Evidence: 1. During resident #1?s record review with staff #1 and staff #2, the resident admitted to the facility on 11/13/2019. The current Individualized Service Plan dated 11-14-2019 documented ?resident?s apartment is located in a secured and supervised unit? with a date identified as 11-14-2019. Staff #1 could not locate and/or provide documentation on file of the determination and justification from the licensee, administrator, or designee should determining whether resident #1?s placement in the special care unit is appropriate. 2. During interview, staff #1 and staff #2 acknowledged the facility did not obtain the determination and justification in writing on the appropriateness of resident #1?s placement in the special care unit.
Plan of Correction:	*The Appropriate Placement for Special Care Unit form was completed for Resident #1. *100% audit was completed for all Memory Care residents to assure that each has the Appropriate Placement for Special Care Unit form on file. *The form for Appropriate Placement for Special Care Unit will be added to each move in packet to assure that it is completed prior to admission. Person Reponsible- RNC/ACC/Dir
Standard #:	22VAC40-73-1130-C
Description:	Based on record review and interview, the facility failed to ensure during night hours, when 22 or fewer residents are present, at least two direct care staff members should be on duty at all times in the special care unit. Evidence: 1. Staff #1 provided a copy of the staff written work schedules labeled ?Daily Schedule,? and a copy of the staff time sheets for the following days: 11-13-2019, 11-14-2019, and 11-16-2019. On 11-13-2019 there were 2 residents in care on the special care unit (Mary B?s) and 4 residents on the assisted living unit; on 11-14-2019 there were 4 residents in care on Mary B?s and 6 residents on the assisted living unit, and on 11-16-2019 there were 4 residents in care on Mary B?s and 10 residents on the assisted living unit. A review of the staff written work schedules and time sheets documented the facility did not have two direct care staff members on duty at all times in the special care unit during the following times: A. On 11-13-2019, 3 direct care staff (staff #3, staff #4, and staff #5) were scheduled to work during the 11:00 PM to 7:00 AM shift. The ?Daily Schedule? documented staff #4 was scheduled to work on Mary B?s, staff #5 was scheduled to work on the assisted living unit, and staff #3 was scheduled to work on both Mary B?s and the assisted living unit. The timesheets dated 11-13-2019 documented staff #3 was on break from 2:04 AM to 2:33 AM; leaving 1 staff (staff #4) on duty on the Mary B?s unit from 2:04 AM to 2:33 AM. Staff #4 was on break from 2:49 AM to 3:18 AM; leaving 1 staff (staff #3) on duty from 2:49 AM to 3:18 AM. In addition, staff #5 was on break from 3:24 AM to 3:54 AM, leaving 1 direct care staff on duty on the Mary B?s unit and 1 staff on duty on the assisted living unit. B. On 11-14-2019, 3 direct care staff (staff #3, staff #6, and staff #7) were scheduled to work during the 11:00 PM to 7:00 AM shift. The ?Daily Schedule? documented staff #3 was scheduled to work on Mary B?s and staff #6 and staff #7 were scheduled to work on the assisted living unit. The timesheets dated 11-13-2019 documented staff #3 was on break from 3:00 AM to 3:29 AM; leaving no direct care staff on the Mary B?s unit from 3:00 AM to 3:29 AM. Two direct care staff were not scheduled to work on the Mary B?s unit during the 11:00 PM to 7:00 AM shift. Staff #1 could not provide documentation on file verifying that staff #6 or staff #7 covered the Mary B?s unit while staff #3 was on break. C. On 11-16-2019, 2 direct care staff (staff #7 and staff #8) were scheduled to work during the 11:00 PM to 7:00 AM shift. The ?Daily Schedule? documented staff #7 was scheduled to work on both Mary B?s and the assisted living unit, and staff #8 was scheduled to work on the assisted living unit. Two direct care staff were not on duty on the Mary B?s unit during the 11:00 PM to 7:00 AM shift. 2. During interview, staff #1 acknowledged the facility did not have two direct care staff on duty in Mary B?s during the aforementioned dates and times.
Plan of Correction:	*The facility has increased their staffing numbers in accordance with the increase of new admissions. *The daily schedules have been adjusted to reflect when the ACC (LPN) is on duty in Memory Care. *The RNC and ACC have been instructed to sign in on the daily scheduling sheets when they work and cover an open shift. *Care staff educated on the requirement that a minimum of 2 staff members be on Memory Care at all times. *ACC to review the daily schedules and staffing needs with the RNC and Director weekly and when each new schedule is posted. Person Responsible- RNC/ACC/Dir
Standard #:	22VAC40-73-220-A
Description:	Based on record review and interview, the facility failed to ensure obtain, in writing, information on the type and frequency of the services to be delivered to the resident by private duty personnel prior to direct care or companion services being initiated. Evidence: 1. Staff #1 sent an email to the Licensing Inspector dated 11-20-2019, documenting ?resident #1 exited the safe and secure unit?. We have initiated project life saver and private duty to prevent reoccurrence.? 2. On 11-22-2019, a review of the staff ?Communication Log? dated 11-19-2019 documented ?#503 (Room number confirmed by staff #1 as resident #1)? sitter came in around 6AM.? 3. During resident #1?s record review, staff #1 and staff #2 were asked to provide information on the type and frequency of the services to be delivered to the resident by private duty personnel. Staff #1 and staff #2 were unable to locate and/or provide documentation on file of information on the type and frequency of the services to be delivered to the resident by private duty personnel prior to direct care or companion services being initiated. 4. During interview, staff #1 and staff #2 acknowledged the facility did not obtain in writing, information on the type and frequency of the services to be delivered to resident #1 by private duty personnel prior to direct care or companion services being initiated.
Plan of Correction:	*Documentation of the type and frequency of services was obtained from the licensed agency providing services to Resident #1. *The ACC updated the ISP to reflect the services provided by the licensed agency providing services to Resident #1 *100% audit to be conducted on all resident files to assure that all residents receiving services from providers outside of the community is properly documented. Person Responsible- RNC/ACC/Dir
Standard #:	22VAC40-73-310-A
Description:	Based on record review and interview, the facility failed to ensure in accordance with ? 63.2-1805 D of the Code of Virginia, assisted living facilities should not admit a resident who presents an imminent physical threat or danger to self or others. Evidence: 1. During resident #1?s record review with staff #1 and staff #2, resident #1 admitted to the facility on 11-13-2019. The physical examination form did not document the date of the exam; however, the form was signed by the physician on 11-06-2019 and documented the resident has the following prohibitive condition ?presents an imminent threat or danger to self or others.? In addition, the physician documented ?unable to comprehend? in the comment section beside the prohibitive condition. 2. During interview, staff #1 and staff #2 acknowledged resident #1 admitted to the facility with the aforementioned prohibitive condition per the physical examination form.
Plan of Correction:	*Discharge planning has started for Resident #1. *Private duty sitters are in place with Resident #1, 24 hours a daily, until his discharge. *100% audit will be conducted on all resident records to assure that there are no other prohibitive conditions listed on their physical examination form without appropriate clarification from the health care provider. *The physical examination form will be reviewed and signed off on for all new admissions prior toaccepting the resident for admission. *A post admission audit will be conducted on each resident record following move-in to assure that forms are complete and correct. Person Responsible- RNC/Dir. of Designee
Standard #:	22VAC40-73-460-D
Description:	Based on record review and interview, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs to prevent wandering from the premises. Evidence: 1. On 11-18-2019, the Regional Licensing Office received an incident report from staff #1 regarding resident #1?s elopement from the special care unit (Mary B?s). The incident report documented on 11-17-2019 at 7:00 AM the ?resident exited apartment through window at approximately 6:30 AM by disabling three safety devices on the window. BFM?s noticed resident had exited. Called 911?? On 11-19-2019, the Regional Licensing Office received another incident report from staff #1 regarding another elopement incident involving resident #1. The documented date and time of the incident (Incident #2) was 11-19-2019 at 7:45 AM. Staff #1 stated the resident was located ?within 15 minutes and returned to Bickford.? 2. Resident #1?s ?Progress Notes? documented the following: A. (Date/Time- 11/17/2019 0700) ?Report to RNC res. got up around 6:30. Resident was in apartment using bathroom?[Resident] said no he needed to finish. BFM gave privacy? [Staff] returned and resident had gone out window? [Staff] noticed 2 shovels on windowsill with window locks and screen broken. 911 notified? BFM staff assigned areas to search inside unit and outside of branch. Received phone call from BFM ?someone spotted [resident] by an office house.? 2 BFM?s got in cars searching. Res. found behind courthouse?? B. (Date/Time- 11/19/2019 0715) ?Report to RNC resident left unit through window. Pencil was used to pry open the window locks? 911 notified? BFM care staff directed where to search. BFM found resident near Kellam HS/Navy Federal intersection?? 3. The distance from the facility to Kellam High School is approximately 1.4 miles. In addition, the roads that surround the facility are Princess Anne Road and Nimmo Parkway with a speed limit range of 35 mph to 55 mph; and West Neck Road with a speed limit of 35 mph. 4. Resident #1?s record review with staff #1 and staff #2 documented the following: A. The current Uniform Assessment Instrument (UAI) dated 11-14-2019 documented the resident has wandering behaviors weekly or more. The UAI also documented ?Resident will sometimes wander behind people or in other resident room.? B. The current ISP dated 11-14-2019 documented the resident has wandering behaviors and that the staff will perform 2 hour checks ?staff will check on resident every 2 hours and as needed to ensure [resident] has not fallen or is in need of assistance.? On the days the resident eloped (11-17-2019 and 11-19-2019) the facility documented hourly checks from 9:00 PM to 6:00 AM; however, staff #1 could not locate and/or provide documentation on file of 2 hour checks being performed from approximately 6:01 AM to 8:59 PM. C. The staff ?Communication Log? documented the resident had exit seeking behaviors on 11-16-2019 and 11-18-2019. On 11-16-2019, ?resident #1 grabbed one of the ?big? tool from the life song station and a couple of kitchen tools and went to the back exit door tried to open the door while holding the tools;? and on 11-18-2019, ?#503 (Room number confirmed by staff #1 as resident #1)? resident #1 pacing unit. Removed finger nail clippers and plunger from [residents] room. Resident still trying to mess with window.? D. The ?Assessment of Serious Cognitive Impairment? form dated 11-14-2019 documented ?For the cognitive function- [resident] has no comprehension, unable to solve any problem, no attention to answer to any questions, decrease/no memory, decline judgement, and no insight? Unable to process any reasonable thought. Decline perception.? 5. During interview, staff #1 and staff #2 acknowledged resident #1 had exit seeking behaviors prior to eloping from the facility.
Plan of Correction:	*Items that could be used to dismantle the locking devices on Resident #1 window were immediately removed from the resident?s room and from the Memory Care common areas. *The contractor observed the window and made additional modifications to better secure the window in Resident #1 room. *Supervision checks of Resident #1 were increased to every 30 minutes. *Private duty 1:1 supervision was added during the timeframe when Resident #1 exhibits exit seeking behavior and was increased to daily 24 hour supervision on 12-11-19 and will remain in place until his upcoming discharge. *Care Staff educated on the need to increase supervision of Resident #1 to include monitoring his environment for evidence of tampering with the window. Person Responsible- RNC/ACC/Dir