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Riverside Assisted Living at Warwick Forest
860 Denbigh Blvd.
Newport news, VA 23602
(757) 886-2000

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: Nov. 8, 2019 and Dec. 12, 2019

Complaint Related: Yes

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

Comments:
An unannounced complaint investigation was conducted on 11-08-2019 from 10:53 AM to 3:50 PM, and on 12-12-2019 from 10:05 AM to 12:47 PM in response to allegations of medication management and personal hygiene. 127 residents were in care at the time of the inspection. A tour of the facility was conducted. The following was reviewed: the medication cart on the third floor, resident records, shower schedules, Individualized Service Plans, Uniform Assessment Instruments, Medication Administration Record?s, and physicians? orders. Interviews were conducted with staff and residents. Documentation reviewed supported residents were receiving showers as scheduled. The facility received violations "under" Resident Care and Related Services. The areas of noncompliance were reviewed with the Administrator throughout the inspection and during the exit interview. Based on this investigation, the complaint is valid. 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, 02-13-2020.

Violations:
Standard #: 22VAC40-73-640-A
Complaint related: Yes
Description: Based on record review and interview, the facility failed to implement the facility?s written plan for medication management to ensure each resident's prescription medications ordered for the resident are refilled in a timely manner to avoid missed dosages.
Evidence:
1. On 11-08-2019, during resident #1?s record review with staff #1, the October 2019 Medication Administration Record (MAR) documented the Atorvastatin 10mg tablet was not administered to the resident on 10-22-2019, 10-23-2019, and 10-24-2019. On the back of the MAR, the documented reason for the Atorvastatin 10mg tablet not being administered was ?not given, notified for refill.? Additionally, direct care staff documented that the resident received the Atorvastatin 10mg tablet on 10-25-2019 and 10-26-2019; however, the MAR documented the resident did not receive the Atorvastatin 10mg tablet on 10-27-2019 and the reason for the tablet not being administered was documented was ?not available.?
2. On 11-08-2019, staff #1 provided a copy of the facility?s Medication Management Plan titled ?LHARS- CSG- ALF Medication Management Plan? with an effective date of ?10-21-2019.? The Medication Management Plan documented ?For residents using outside pharmacies? If medications are not received timely, the facility will order from the in house pharmacy to ensure resident receives medications as ordered? If the medication or treatment has not been received within 3 days of the last available dose, the medication/treatment will be ordered from the in house pharmacy.?
3. During interview on 11-08-2019, staff #1 acknowledged that the facility did not implement their medication management plan to ensure resident #1?s Atorvastatin 10mg tablet was refilled in a timely manner to avoid missed dosages.

Plan of Correction: 1. Medication for resident #1 medication was received on 10/25/2019. The resident?s POA was notified on 10/25/2019 in regards to the community policy and procedure on residents who utilize outside pharmacies by the administrator. The physician was notified of all variances in doses. Another notification to the family will be issued to ensure understanding and compliance.
2. All new admissions and Residents/ POAs who do not use the facility?s preferred pharmacy will be educated on the facility?s medication management policy. If the facility is not in receipt of medication prescribed within 3 days prior to being out of medication, the medication will be ordered and delivered by the community pharmacy. The Unit Managers and/or the Assisted Living Director will conduct an audit of all current medication to ensure timely receipt. All providers will be notified of any variances.
3. The Unit Managers and/or designee will keep a log of all medications for each resident who currently uses an outside pharmacy. The log will be monitored weekly by the unit manager to ensure that all medication is present in the community. POA?s will be contacted within 15 days of the upcoming need for medication by the Unit Manager or designee.
4. The Administrator and Unit Managers or their designees will conduct random audits of the residents who use outside pharmacies to ensure the policy is being followed accordingly. All findings will be corrected and reported to the QA Committee for continued improvement and analysis.

Standard #: 22VAC40-73-650-E
Complaint related: No
Description: Based on record review and interview, the facility failed to ensure the resident's record contained the physician's or other prescriber's signed written order in the resident's record.
Evidence:
1. During resident #3?s record review with staff #1, the October 2019 Medication Administration Record documented Cephalexin 500mg was administered on 10-23-2019 through 10-25-2019, and Ibuprofen 600mg was administered on 10-23-2019, 10-26-2019, and 10-27-2019. Staff #1 could not located and/or provide physician?s signed written orders for the Cephalexin 500mg nor Ibuprofen 600mg at the time of the inspection on 11-08-2019.
2. During interview, staff #1 acknowledged resident #3?s record did not contain physician?s or other prescriber?s written orders for the aforementioned medications.

Plan of Correction: 1. Resident #3?s physician was contacted by the Unit Manager to obtain a copy of the order for medication. The order was in the resident record el
2. Residents and families who do not use facility clinic will be educated on the importance of bringing a copy of all new orders when given by the physician. An audit of all new orders received in the last 30 days will be conducted to ensure that proper procedures are followed.
3. Staff will be re-educated that any new medication presented for administration must have written prescriber orders.
4. A weekly audit of up to 10 new residents will be completed by the Administrator/or designee with new orders for 6 weeks to ensure all required signatures are present. All findings will be corrected and reported to the QA Committee for continued improvement and analysis.

Standard #: 22VAC40-73-660-A
Complaint related: No
Description: Based on observation and interview, the facility failed to ensure the storage area for medications was locked.
Evidence:
1. On 11-08-2019 at approximately 11:08 AM, a file cabinet drawer located on the 3rd floor near room #304 was left open and was unattended. The following medications were observed in the drawer: Pramipexole .125mg (2 bubble packs containing 90 pills per pack); Metformin 500 mg (3 bubble packs containing 30 pills per pack); and Enema Phosphate (3 bottles). The file cabinet did not contain a locking device.
2. Staff #4 acknowledged the medications were not stored in a locked storage area.

Plan of Correction: 1. The storage area for all medication was immediately placed in a locked area by the unit manager.
2. The Nurse Educator/or designee will educate the staff on the importance of keeping all areas that contain medication locked and secured. During new hire orientation, the nurse educator/ or designee will review with all licensed health care professionals this policy and procedure to ensure safety to all residents.
3. Medication that is not in use will be secured in a locked cabinet where only licensed health care professionals can obtain entry if needed.
4. The Administrator and/or designee will perform random audits and walk-throughs on the unit to ensure compliance. All findings will be corrected and reported to the QA Committee for continued improvement and analysis.

Standard #: 22VAC40-73-680-B
Complaint related: No
Description: Based on observation and interview, the facility failed to ensure medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident.
Evidence:
1. On 12-12-2019, during interview with resident #1, a weekly pill organizer was observed in the resident?s room. The weekly pill organizer contained A.M and P.M pills in the Friday, Saturday, Sunday, and Monday sections. Staff #2 identified the pills in the weekly pill organizer as the following:
A. A.M medications: B12 (pink round tablet), Aspirin (white round tablet), Glimipride (green oval tablet), Lipitor (white oval tablet), Cephalexin (red and tan oblong tablet), Metoprolol (white round tablet), Ferrous Sulfate (black round tablet), and Pantoprazole (yellow oval tablet).
B. P.M medications: Ferrous sulfate (black round tablet), Cephalexin (red and tan oblong tablet), Metoprolol (white round tablet), Mirtazapine (white oval tablet), and Quetiapine (pink half tablet).
2. During interview, staff #1 and staff #2 acknowledged the facility did not keep resident #1?s medications in the pharmacy issued container until the medications were administered to the resident.

Plan of Correction: 1. Resident #3?s prepacked medication in a non-pharmacy issued container was disposed of by the Interim Administrator and the resident was given medication in the original pharmacy packaging to take for leave of absence on 11/8/2019.
2. The Nurse Educator/or designee will educate the staff on the facility policy as well as state/federal regulations in regards to repackaging medication.
3. Medication that is needed for all Leave of Absence will remain in all original containers. During Orientation and quarterly, training will be provided to all staff in regards to the regulation relating to medication repacking.
4. The Licensed Nurse on duty/ or designee will review all leave of absence medication. A current physician?s order will be provided to the Responsible Party to ensure accurate administration of medication. The Licensed Nurse on duty will verify that all medication is packaged appropriately and according to state/federal regulation. All findings will be corrected and reported to the QA Committee for continued improvement and analysis.

Standard #: 22VAC40-73-680-D
Complaint related: No
Description: Based on record review and interview, the facility failed to ensure medications are administered in accordance with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
Evidence:
1. 18 VAC 90-60-110 Standards of practice in the Virginia Board of Nursing Registered Medication Aide Curriculum documents, ?A medication aide shall not: Administer by intramuscular or intravenous routes.?
2. During resident #2?s record review with staff #1, August and September 2019 Medication Administration Records (MAR) documented resident #2?s Cyanocobalamin injection was administered by staff #2, Registered Medication Aide (RMA) on 08-15-2019 and on 09-30-2019 by staff #3, RMA.
3. Resident #2?s signed physician?s prescription dated 06-10-2019 documented ?Cyanocobalamin (Vitamin B-12) 1000 mcg/mL injection- inject 1mL into the muscle twice a month.?
4. During interview, staff #1 stated staff #2 and staff #3 signatures were documented on the August and September 2019 MAR?s and acknowledged both staff are RMA?s and administered the Cyanocobalamin injection to resident #2 on the aforementioned dates.

Plan of Correction: 1. Staff #2 and Staff #3 have been required to take a 4 hour refresher course on medication to ensure understanding medication administration according to their scope of practice. Resident #2?s B-12 injections have been routinely scheduled monthly with his physician to ensure that the injection is being given according to the prescribers orders.
2. Facility will review all residents who been identified as having a prescriber?s order for an intramuscular injection medication to ensure that a licensed health care professional is administering according to their scope of practice. Individualized service plans will be updated to reflect the administration of the intramuscular injection should be given by a licensed practical nurse (LPN/LVN).
3. Residents identified as needing an intramuscular injection medication will be scheduled with their physician monthly to obtain that medication or the unit manager/designee will be assigned to administer medication.
4. The Unit Managers will conduct a random audit of 10 residents for six (6) weeks to ensure that medication is administered by the appropriate healthcare professional. All findings will be corrected and reported to the QA Committee for continued improvement and analysis.

Standard #: 22VAC40-73-680-I
Complaint related: No
Description: Based on record review and interview, the facility failed to ensure the Medication Administration Record (MAR) included the initials of direct care staff administering the medication.
Evidence:
1. During resident records reviewed with staff #1, the following dates on the October 2019 MAR for resident #1 and resident #2 did not include the initials of direct care staff who administered the following medications:
A. Resident #1?s Naproxen Sodium 220mg tab on 10-15-2019 at 5:00 PM; Quetiapine 25mg tab on 10-17-2019 at 2000; and Tylenol 325mg tab on 10-20-2019 and 10-29-2019 through 10-31-2019 at 2300.
B. Resident #2?s Donepezil 5mg tab on 10-19-2019 and 10-27-2019 at 2000; Fish Oil 1,000 mg cap on 10-16-2019 at 0900 and on 10-27-2019 at 1600; Magnesium Oxide 500mg tab on 10-16-2019 at 0900; Metformin 500mg tab on 10-16-2019, 10-23-2019, and 10-24-2019 at 0900, as well as on 10-27-2019 at 1600; and Polyethelyene glycol powder, Fluvoxamine ER 100mg cap, and Quetiapine 25mg tab on 10-16-2019 and 10-24-2019 at 0900.
2. Additionally, resident #1?s November 2019 MAR was left blank on 11-03-2019 through 11-30-2019, and did not include the initials of direct care staff who administered the following medications: Aspirin 325mg tab, Atorvastatin 10mg tab, Ferrous Sulfate EC 325mg tab, Glimepiride 2mg tab, Metoprolol 25mg tab, Humalog 100 U/ML, Lidocaine 4% patch, Mirtazapine 7.5mg tab, Naproxen Sod 220mg tab, Pantoprazole 40mg tab, Quetiapine 25mg tab, and Tylenol 325mg tab.
3. During interview, staff #1 acknowledged the dates on resident #1?s October and November 2019 MAR and resident #2?s October 2019 MAR were left blank and did not include the initials of the direct care staff who administered the medications.

Plan of Correction: 1. Resident #1?s MAR was reviewed by the nurse manager/designee. The resident?s representative and physician were notified of the missed documentation of administration.
2. A 100% audit will be completed of the current month of all residents? MAR for missed documentation by unit managers/designees. All findings will be corrected and reported to the QA Committee for continued improvement and analysis.
3. Education regarding medication administration and record keeping provided to the nursing staff by the nurse managers. Nurses and RMAs will be observed by the Nurse Educator/designee every 3 months. Facility educator will conduct at least 3 medication administration observation monthly.
4. The process be reviewed by the Administrator/designee monthly for 3 months by an audit of 10 MARs. All findings will be corrected and reported to the QA Committee for continued improvement and analysis.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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