VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Nov. 20, 2019 and Jan. 9, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced complaint inspection was conducted on November 20, 2019 from 9:26 a.m. to 2:15 p.m. and on January 9, 2020 from 9:48 a.m. to 12:59 p.m. regarding resident falls and resident care. There were 30 residents in care on November 20, 2019, and 32 residents in care on January 9, 2020. The complaint is valid. The following was discussed: Individualized Service Plans signatures after updates, Falls Management policy, updating Uniform Assessment Instruments (UAIs) with a change in condition, and accuracy of identified needs in UAIs. 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.

Violations:

Standard #:	22VAC40-73-325-B
Complaint related:	Yes
Description:	Based on record review and interview, the facility did not ensure the fall risk rating was reviewed and updated after a fall. Evidence: 1. ?Progress Notes? dated 11/10/19 documented resident #1 fell, and complained of lower mid-back and left hip pain. The record did not contain a fall risk rating. 2. Resident #1?s Uniform Assessment Instrument (UAI) dated 11/11/19 documented ?Assisted Living? level of care. The comprehensive Individualized Service Plan (ISP) was completed on 10/29/19. 3. Staff #4 acknowledged there was no fall risk rating for the documented fall.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-460-D
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to provide supervision of resident care, including attention to specialized needs, such as prevention of falls. Evidence: 1. Resident #2?s record documented six falls: 4/4/19, 4/16/19, 4/30/19, 5/10/19, 5/26/19, and 5/31/19. Four of the six falls resulted in injuries: a. 4/4/19, fracture to left shoulder and left elbow; b. 4/16/19, sutures to right side of forehead c. 5/26/19, dislocated right hip, and d. 5/31/19, hematoma to left side of forehead. 2. Resident #3?s record documented nine falls: 10/20/18, 3/22/19, 7/25/19, 7/31/19, 8/7/19, 9/9/19, two on 9/12/19, and 9/28/19. Two of the nine falls resulted in injuries: a. 7/31/19, hematoma to left side of forehead, and b. 9/9/19, hematoma/laceration to forehead. 3. Staff #3 and staff #4 acknowledged resident #2 and resident #3 falls.
Plan of Correction:	Not available online. Contact Inspector for more information.
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 injury, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional was secured immediately. Evidence: 1. ?Progress Notes? in resident #1?s record dated 11/10/2019 ? 18:24 documented, ?S/P FALL, Resident c/o lower mid-back pain and left hip pain. Because resident is unable to bear weight on his left leg, staff transported resident to dinning room in a wheel-chair. Writer transported resident back to his apartment to check for bruises, Resident is unable to turn from side-to-side without pain and discomfort. Writer notify Manager on duty with details. F/U notes placed in MD chart to follow-up.? The note was signed by staff #1. 2. ?Progress Notes? in resident #1?s record dated 11/11/2019 ? 06:39 documented, ?Resident still c/o pain to lower back upper buttock area. Assisted with transfer to bed from the wheel chair where I noticed a bruise on [resident #1?s] left arm.? The note was signed by staff #2. ?Progress Notes? in resident #1?s record dated 11/11/2019 ? 12:15 documented, ?Resident complaining to left hip, buttock pain. Resident yells out when coming from a sitting to standing position and has pain when attempting to walk. Resident last known fall was October to which he had no injuries and has not complained of pain until this past weekend?? The note was signed by staff #3. 3. An incident report received by the regional licensing office on 11/13/19 documented, ?On 11/12/19 at 0637 Care staff noted [resident #1?s name] in the floor beside his bed attempting to get out of bed on his own and stated that he fell... [Resident #1?s name] was transported to [hospital name] and seen by ED. Staff called to check on status of resident and was told [resident?s name] was admitted due to (closed, non-displaced sacrum fracture). MD made aware.? 4. Staff #3 acknowledged that resident #1 fell 11/10/19, and medical attention from a licensed health care professional was not secured immediately.
Plan of Correction:	Not available online. Contact Inspector for more information.