VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Salem
2001 Ridgewood Drive
Salem, VA 24153
(540) 494-8594

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: Nov. 19, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

On 11/19/2019 one inspector conducted an inspection related to a self-reported incident involving a resident being served food to which she was allergic. During the inspection and at the exit interview, the facility was given the opportunity to discuss the violations and to show that they were in compliance. Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must contain the following: 1) steps to correct the noncompliance with the standard(s); 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). If you have any questions, please contact your licensing inspector at 540-309-3043.

Violations:

Standard #:	22VAC40-73-460-A
Description:	Based on document review, the facility failed to assume general responsibility for the health, safety, and well-being of a resident. EVIDENCE: 1. According to facility paperwork (Incident Report sent to licensing dated 8/27/2019, and facility Incident Investigation Report dated 8/30/2019), resident 1 is allergic to shellfish. On 8/27/2019 both reports shows resident 1 was served shellfish for dinner. The resident was prescribed Benadryl by the physician. Resident 1 took the medication for approximately 24 hours, and suffered two falls during that time period, resulting in a trip to the hospital. The Benadryl was discontinued after the falls.
Plan of Correction:	The following is a summary of the Plan of Correction for Brookdale Salem. This Plan of Correction is in regards to the Self Report and subsequent Complaint Inspection dated November 19th, 2019. This Plan of Correction is not to be construed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regulatory requirements. In this document, we have outlined specific actions in response to identified issues. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. Corrective Action 1). Residents food allergies are made available to staff by the Health and Wellness Director / Designee and updated monthly and as changes occur. Unable to retroactively correct the Benadryl medication administration resulting in fall. How to Identify Others 1). The records for residents with allergies have been audited to verify that these food allergies are identified clearly. An audit will be conducted by the Health and Wellness / designee to verify as needed orders are entered appropriately into the EMAR system. Systemic Changes 1). Re-training of Nursing, Direct Care and Dietary staff by the Health and Wellness Director, to include new hires on observing food allergies. Additional education on entering as needed orders in to the EMAR system will be conducted no later than 02/29/20. Monitoring 1). The Health and Wellness Director / Designee will conduct a weekly audit times four (4) weeks to verify food allergies are accurate and made available to staff. An audit of as needed medication orders will be conducted by the Health and Wellness Director to verify accuracy.