VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Chambrel Williamsburg
3800 TREYBURN DRIVE
Williamsburg, VA 23185
(757) 220-1839

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Dec. 30, 2019 and Feb. 10, 2020

Complaint Related: No

Areas Reviewed:

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

Comments:

An unannounced monitoring inspection was conducted on 12-30-19 (ar 11:15 am/dep 14:10 pm) and 2-10-20 (ar 10:40 am/dep 1:50 pm). The census on 2-10-20 was 110. The administrator was present. A review of the missing medication was discussed and a review of the facility's medication policy was reviewed and discussed. The acknowledgement form was signed. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendars of receipt (2-29-20).

Violations:

Standard #:	22VAC40-73-660-A
Description:	Based on document review and staff interviews, the facility failed to ensure Schedule II drugs and any other drug subject to abuse storage cabinet was kept locked. Evidence: 1. On 12-30-19 during the inspection into alleged missing controlled medications from the medication cart located on the first floor of building three, staff #1 informed the inspector of staff #1 and staff #5 also having keys to the medication cart. However, staff #1 stated not knowing the keys in possession were to the medication cart. 2. Staff #5 was interviewed and also stated having keys but not knowing keys in possession were to the medication cart. 3. On 12-30-19, the inspector requested to check the medication cart and was accompanied by staff #1 and staff #2. A check of the cart was completed to determine if the controlled medication storage could be accessed without a key or determine if the entire cart could be accessed without a key. 4. Staff #3 was interviewed regarding the missing medication during staff's shift. Staff stated counting all control medications according to facility policy with staff #4 on the morning of 12-19-19 during shift change. There were no missing controlled medications during shift count. 5. Staff #5 was interviewed and stated counting controlled medication with staff #3 during the morning shift change. All medications were present when staff left facility. 6. According to staff #3, on the afternoon of 12/19/19, staff went to administer resident #1's Xanax and could not locate the medication on the medication cart. During further search of the cart staff stated resident #2's Lorazepam was also discovered missing. 7. Staff #1 and #3 acknowledged resident #1's Xanax and resident #2's Lorazepam were missing from the first floor medication cart on the afternoon of 12-19-19.
Plan of Correction:	The following is the Plan of Correction for Brookdale Chambrel Williamsburg regarding the Statement of Deficiencies dated 12/30/19. 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. We remain committed to the delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 22VAC40-73-(6)-660-A Keys to the medication carts and narcotic boxes are kept together and the medication passers that shift are in control of these keys. An extra set of keys to the medication cart and narcotic box are kept locked in the key box accessible only to the Health and Wellness Director. Staff #5 no longer has a set of medication keys. The medication cart cannot be accessed without a set of keys and it is the medication passer of that shift who would have access to the medications and the narcotic box. The Health and Wellness Director or designee will audit medication carts and the assigned keys for extra keys and place extra keys in the locked key box. Audit completed 2/12/2020. The pharmacy will replace the locks to the medication carts and narcotic boxes and provide new sets of keys. A set of keys will be exchanged at narcotic count at each shift change between the medication passers of each medication cart. New keys and locks completed 2/15/2020. The Health and Wellness Director or designee will audit 10% of medication carts and narcotic count sheets weekly for documentation, observation of medication passes, and observation of shift to shift narcotic count. The results of these audits will be discussed in the quality assurance meetings. Medication passers will be re-educated on Medication Management Policy and Procedures. Responsible party is the Health and Wellness Director. Completion date: 3/29/2020 and on going