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: Oct. 24, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced complaint inspection was conducted by two Licensing Representatives on October 24, 2019 from 9:09 a.m. to 2:32 p.m. There were 68 residents in care. The complainant?s concerns were regarding notification of fall and resident assessment. The complaint was valid. The following was discussed during the inspection: notification to licensing office, and appropriateness of safe, secure environment placement. 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 #:	22VAC40-73-460-F
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to notify the next of kin, legal representative, or designated contact person of any incident of a resident falling, whether or not it results in injury. This notification shall occur as soon as possible but no later than 24 hours from the time of initial discovery or knowledge of the incident. Evidence: 1. Resident #1?s record contained notes from the direct care staff documenting the resident was found on the floor on 10/12/19 at 11:40 p.m. Another note dated 10/14/19 - 3:31 p.m. documented, ?Hospice nurse and nurse practitioner were in this afternoon to evaluate residents hip and per the nurse practitioner #2 and after and after speaking with the [family?s name] she is being sent out via 911 to the hospital for further eval.? 2. ?Follow up charting? dated 10/14/19 - 6:14 p.m. documented, ??I informed the [family?s name] who was at the community that I had called hospice and the hospice nurse and I left a message? the resident family is aware and was at the community during transport.? 3. Staff #3 and staff #5 confirmed the incident occurred on 10/12/19 at 11:40 p.m. and family was not notified of the incident until 10/14/19.
Plan of Correction:	Resident is no longer at community. Resident Care Director reported incident on the morning of 10/14/2019 when alerted of incident. Resident Care Director and Executive Director provided staff #1 with a final written warning and reviewed commonwealth policies and procedures regarding proper notifications of resident with falls and possible serious injuries.
Standard #:	22VAC40-73-470-F
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure when the resident suffers serious accident or injury, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional was secured immediately. Evidence: 1. Resident #1?s record contained a note dated 10/14/19 - 8:18 a.m. documenting, ?Late Entry: 10/12/19 11:40 p.m. Fall resident was found on her knees learning over her bedside comc. Resident stated that she was trying to use bedside como, we sat resident down on her bottom felt legs, arms, head for any bruise or broken, resident did complain that her right leg hurt a little, I asked resident could she get up and she stated yes we sat her in her chair?? The note was signed by staff #1, who is employed as a registered medication aide. There was no documentation of resident #1 refusing medical attention from a licensed health care professional. 2. Additionally, resident #1?s record contained a note dated 10/13/19 - 9:30 p.m. documenting, ?Follow up charting Resident in her bed this evening she is unable to bare any weight when standing and she is complaining of pain in her upper right leg around the thigh/hip area and it appears to be very swollen hospice was called to come and see her because of her possible change in condition hospice nurse [hospice nurse name] arrived around 9pm and checked resident she then spoke with the [doctor?s name] and he ordered a x-ray of her right hip awaiting on mobile x-ray to arrive.? The note was signed by staff #2, who is employed as a registered medication aide. 3. Also, resident #1?s record contained a hospice note dated 10/14/19 documenting, ?Received xray results; @ 1325 of fracture nurse practitioner and this nurse went to evaluate; son notified spoke with nurse practitioner recommended further evaluation by hospital?? The note was signed by hospice nurse #1. 4. City of [city name] Fire-Rescue ?Prehospital Care Report Summary? dated 10/14/19 documented, ?PT complaining of pain on her right leg. Noted deformity and swelling on upper right leg. Caregiver stated that pt fell 2 days ago. Caregiver stated that their mobile X-ray showed fracture on the right and left pelvis.? 5. ?Emergency Department (ED) Provider Notes? dated 10/14/19 documented, ?Closed displaced comminuted fracture of shaft of right femur, initial encounter.? Additionally, annotated images in ED Notes document ?Obvious fracture/deformity.? 6. During interview with staff #3 and staff #5, staff #5 stated staff #1 was disciplined. Staff #1 was provided a final written warning by staff #3 and staff #5 on 10/16/19 for the following: ?Employee failed to call hospice and the family member when the resident was noticed on the floor. Resident has injury to her right leg? failed to follow policies and procedures on evaluations and sending residents for emergency care.? 7. Staff #3 and #5 confirmed the aforementioned information regarding resident #1?s injury and medical attention was not secured immediately from a licensed health care professional for resident #1.
Plan of Correction:	Resident is no longer at community. Executive Director and Resident Care director reported and sought out emergency care for resident as soon as they were notified of incident. Resident Care Director and Executive Director provided staff #1 with a final written warning and reviewed commonwealth policies and procedure with resident falls and possible serious injuries.
Standard #:	22VAC40-73-680-H
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure at the time the medication is administered, the facility documented on a medication administration record (MAR) all medications administered to residents. Evidence: 1. The facility?s ?End of Shift Report? dated 10/12/19 on the 11-7 AM shift, staff #1 documented resident #1 was found on the floor on 10/12/19 during the 11- 7 AM shift. The report documented ??We sat resident on floor on her bottom, vitals 157/62 p77 I asked was she hurting and she stated her R leg/hip was hurting a little I asked her could she stand and she stated yes we put her In her recliner. I checked for any broken bones or bruises. I gave resident some pain medication...? 2. The October 2019 MAR did not document pain medication being administered to resident #1. 3. Staff #3 observed and confirmed that staff #1 failed to document on the October 2019 MAR the pain medication administered to resident #1.
Plan of Correction:	Resident is no longer at community. Resident Care Director reviewed with Staff #1 proper medication documentation procedures. Resident Care Director and Assistant Resident Care Director will continue with current MAR audits to assure continued compliance.