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Brookdale Virginia Beach
937 Diamond Springs Road
Virginia beach, VA 23455
(757) 493-9535

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: Dec. 20, 2019

Complaint Related: No

Areas Reviewed:
22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:
A Licensing Representative conducted an unannounced monitoring inspection in response to a self-reported incident of resident to resident physical abuse on December 20, 2019 from 11:45 a.m. to 4:05 p.m. There were 31 residents in care. Topics discussed included the following: Administrator justification for placement, and maintaining a list of aggressive residents in care.

Violations:
Standard #: 22VAC40-73-440-H
Description: Based on record review and interview, the facility failed to ensure reassessments due to a significant change in the resident?s condition, using the Uniform Assessment Instrument (UAI), was utilized to determined whether a resident?s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident.

Evidence:

1. A ?General Progress Note? in resident #2?s record dated 08/17/2019 - 22:52 documented the following, ?Resident becomes easily frustrated and angry at other residents for walking and opening doors around the community. He asks staff why they can?t be stopped. If a resident is at [resident #2?s name] door, the resident is redirected without trouble. [Resident #2?s name] is redirected away from the residents and reminded that this is a dementia care community and the residents have the right to walk around freely. Resident threatens to ?call his lawyer?. Resident is reminded to keep his door locked since he is able to keep up with his key and locking his door.? The note was documented by staff #3.

2. Additionally, a Progress Note dated 09/09/2019 by [Family Nurse Practitioner #1] documented the following, ?Discussed patient?s status with staff they indicated that patient has had residents to enter his room during the evening. Discussed the importance of safety with the staff and encouraged them to monitor patient closely due to posttraumatic stress and psychosis? Plan:? Keep residents from patient?s room?.

3. Resident #2?s most current Uniform Assessment Instrument (UAI) dated 10/08/2019 documented the resident?s behavior pattern as ?Appropriate.? Resident #2?s most current Individualized Service Plan (ISP) dated 10/15/2019 documented, ?A. [Resident #2?s name] does have abnormal behaviors. B. [Resident #2?s name] can become angry and agitated when other residents open his apartment door. He get very paranoid and protective. C. Staff to monitor and redirect when other residents are walking around apartment doors and will redirect [resident #2?s nickname] and remind him when they mean no harm. Staff will observe [Resident #2?s name] over the next year for any changes in behavior and alert MD. [Resident #2?s nickname] to have evaluation for continued appropriateness ? staff to monitor and observe q shift until seen.?

4. Staff #1 observed and confirmed resident #2?s UAI did not address resident #2?s behaviors to determine whether a resident?s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident.

Plan of Correction: 1. Immediate correction was made on the same day of the survey; the records of resident #1 and resident #2 reviewed and Uniform Assessment Instrument (UAI) of resident #2 corrected by the health and wellness director. Resident representative and provider notified.

2. An audit of the UAIs will be conducted by the health and wellness director/resident care coordinator/designee to ensure the residents' behavioral assessments are current.

Findings will be corrected by the health and wellness director/designee and will be reviewed with the next Collaborative Care Review (CCR) meeting for quality assurance.

3. In service re-training, related to managing aggressive behaviors, how to evaluate and report was provided to the nursing staff by the health and wellness director/designee.

4. The process will be reviewed by the Executive Director/designee monthly for 3 months with an audit of 4 residents' annual service plan evaluation.

Findings and corrective actions will be reviewed with the next CCR meeting for quality assurance, continued implement and analysis. Additional corrective action will be implemented by the Executive Director based on the findings.

Standard #: 22VAC40-73-550-C
Description: Based on record review and interview, the facility failed to ensure residents were free from physical abuse, as provided in 63.2-1808 of the Code of Virginia.

Evidence:

1. An incident report received on 12/16/2019 by the regional licensing office documented, ?Resident [resident #1?s name] was walking around the community doing his normal day to day opening room doors, looking then closing the door back. Staff heard [resident #2?s name] yell, ?You want some more? and then charged at [resident #1?s name] punching him to the left ear/head area. [Resident?s #1?s name] did not fall and staff ran to quickly break up the altercation. Residents were separated? [resident #1?s name] had noted cut to left ear??

2. A Progress Note in resident #2?s record dated 10/10/2019 by [Doctor?s name #1] documented the following, ?He says that he is feeling well, but the staff is concerned about some of his interactions with another resident who seems to be able to annoy him and make him angry. He has threatened this other resident with mean spirited deeds.?

3. Subsequently, ?Progress Notes? dated 12/15/2019 18:30 in resident #1?s record documented the following, ?Resident was hit/punched in the left ear/side of head by another resident. He has a little skin tear to his left ear and redness, he also c/o pain when he was check. ?(per witness) She was coming out of the Laundry C area when she heard another resident yelled ?You want some more.? and she quickly ran to see what was going on and saw this male resident charged at another male resident and punched him in the left ear/left side of head in the hallway. After he got hit and walked away he said that ?Are you trying to kill me?. Family/POA was notified regarding incident, and also was told that he needs to be check out due to he was hit by another resident, does she want us to call 911 or does she will take him to ER to be check. VSS-133/78, 90, 20, 97.5. Around 820pm POA came and took resident to ER for evaluation.? The note was documented by staff #2.

4. Staff #1 observed and confirmed resident #2 punched resident #1, and resident #1 received a cut to his left ear as a result of the incident.

Plan of Correction: 1. On the day of the incident, Resident #1 and resident #2 assessed by the nurse and reported to the primary care providers. Resident #1 was sent to the emergency room due to the small scratch and redness on the left ear. He returned back to the community on the same day with no additional order. The residents' medication regimen was reviewed by their Primary Care Providers (PCP). Resident #2's medications were adjusted.

2. An audit of the UAIs will be conducted by the health and wellness director/resident care coordinator/designee to ensure residents' behavioral assessments are current.

Findings will be corrected by the health and wellness director/resident care coordinator/designee and will be reviewed with Collaborative Care Review (CCR) meeting for quality assurance, continued implement and analysis.

3. In service re-training to nursing staff regarding routine rounding, observing the behavioral changes, redirecting, supervision, shift reporting and reporting to the health and wellness director/designee.

4. The process will be reviewed by the Administrator/designee for 3 months with an audit of 2 residents' annual service plan evaluation.

Findings will be corrected and discuss during the Collaborative Care Review (CCR) meeting for continued quality improvement and analysis.

Disclaimer:
A compliance history is in no way a rating for a facility++.

The online compliance history includes only information after July 1, 2003. In addition, the online compliance history includes information regarding adverse actions that may be the subject of a pending appeal. An adverse action is not final until a provider has exhausted or waived all due process rights. For compliance history prior to July 1, 2003, or information regarding the status of pending adverse actions, please contact the Licensing Inspector listed in the facility's information. The Virginia Department of Social Services (VDSS) is not responsible for any errors in or omissions from the compliance history information.

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