VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Shenandoah Place, Inc.
50 Burkholder Lane
New market, VA 22844
(540) 740-4300

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: March 17, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

This inspection is in response to a complaint that was received in the licensing office on 03/17/2020 relating to the allegation of medication mismanagement. The information gathered during this investigation supports the allegation, so the complaint is determined to be valid. The facility is required to submit an intensive plan of correction the the licensing office by 04/02/2020. Following administrative review, the findings of this inspection report, have been amended and revised on 11/19/20. If you have any questions, please contact the licensing inspector at (540) 332-2330 or email rhonda.whitmer@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-70-C
Complaint related:	No
Description:	Based upon an interview and a review of resident's medication administration records, the facility failed to ensure a written report was submitted to the licensing office within seven days of a major incident that threatens the life, health, safety or welfare of a resident. EVIDENCE: 1) Resident A has the following order effective 03/02/20: Isosorbide MN ER 30mg-Take 1/2 tablet (15mg) by mouth every day for Hypertension. a. Communication received in the licensing office on 03/17/20 indicates resident A has not received medication from 02/28/20 through 03/16/20. b. The Medication Administration Record for resident A indicates medication was not available for administration from 02/28//20, 02/29/20 and 03/02/20 through 03/18/20. c. Documentation in the MAR indicates medication was administered on 03/01/20. d. The LI interviewed the facility nurse and the administrator on 03/18/20 who stated that medication was not available for administration since 02/28/20.
Plan of Correction:	Intensive Plan of Correction Required.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based upon review of resident's records, the facility failed to ensure assessed needs are included on the Individualized Service Plan (ISP). EVIDENCE: 1) The Uniform Assessment Instrument (UAI) for resident A indicates no assistance is needed with toileting. The ISP indicates mechanical support of handrail. 2) The UAI for resident A indicates mechanical assistance only with bathing. The ISP indicates staff provides supervision during bathing for safety.
Plan of Correction:	Intensive Plan of Correction Required.
Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based upon a review of the facility's medication management plan, the facility failed to implement procedures addressed in the plan and failed to ensure the plan was current to meet the regulations effective 02/01/2018. EVIDENCE: 1) The facility failed to follow the methods to ensure that each resident's prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. a. The facility medication management plan indicates if a medication is not available at the scheduled time of administration, the pharmacy will be notified, an entry made in the pharmacy communication notebook, and the supervisor will be notified. Charting "med not available' on the MAR alone does not fulfill this requirement. b. Resident A has the following order effective 03/02/20: Isosorbide MN ER 30mg-Take 1/2 tablet (15mg) by mouth every day for Hypertension. c. Communication received in the licensing office on 03/17/20 indicates resident A has not received medication from 02/28/20 through 03/16/20. d. The Medication Administration Record for resident A indicates medication was not available for administration from 02/28//20, 02/29/20 and 03/02/20 through 03/18/20. 2) The medication management plan indicates a weekly review of the medication administration records will be completed by the nurse, administrator or medication aide supervisor to ensure accurate and complete documentation. 3) The medication management plan does not include methods for verifying medication orders have been accurately transcribed to the medication administration records (MARs) within 24 hours of receipt. 4) The medication management plan does not include methods to ensure that MARs are maintained as part of the resident's record. 5) The medication management plan does not include methods to ensure residents do not receive medications or dietary supplements to which they have known allergies. 6) The medication management plan does not include procedures for internal monitoring of the facility's conformance to the medication management plan. 7) The facility medication management plan indicates the last update as 03/2016 and identifies a previous employee as the administrator.
Plan of Correction:	Intensive Plan of Correction Required.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based upon review of resident's records, the facility failed to ensure medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1) Resident A has the following order effective 03/02/20: Isosorbide MN ER 30mg-Take 1/2 tablet (15mg) by mouth every day for Hypertension. a. Communication received in the licensing office on 03/17/20 indicates resident A has not received medication from 02/28/20 through 03/16/20. b. The Medication Administration Record for resident A indicates medication was not available for administration from 02/28//20, 02/29/20 and 03/02/20 through 03/18/20. c. Documentation in the MAR indicates medication was administered on 03/01/20. d. The LI interviewed the facility nurse and the administrator on 03/18/20 who stated that medication was not available for administration since 02/28/2 2) Resident A has the following order: Reguloid Psyllium powder- Mix one tablespoonful with 8 ounces of water and drink by mouth daily for bowel control. a. Documentation in the MAR indicates resident refused on 02/24/20, 02/25/20, 02/26/20, 02/27/20, 02/29/20 and on 03/03/20 due to having loose stools. There is no documentation of physician notification. b. Documentation in the MAR indicates resident refused on 03/04/20, 03/06/20 and 03/09/20 through 03/14/20 due to wanting the order to be changed to as needed. There is no documentation of physician notification. 3) Resident A has the following order: Furosemide 80mg-Take one tablet by mouth twice daily for congestive heart failure. Times of administration on MAR are 8:00am and 4:00pm a. Documentation in the MAR indicates medication was not administered on 02/23/20 at 8:00am due to " resident out" and on 02/23/20 documentation at 6:06pm medication was held "per administrator to avoid further dehydration until we speak with resident's PCP. b. There is no documentation of physician notification. c. Documentation in the MAR indicates resident refused medication on 02/24/20 at 9:07am, 02/24/20 at 3:57pm, 02/25/20 at 9:24am "resident stated still not feeling good.", 02/25/20 at 5:04pm; 02/26/20 at 8:23am " resident stated still feeling weak", 02/26/20 at 4:44pm, 02/27/20 at 8:04am, 02/27/20 at 4:21pm and 02/29/20 at 4:37pm. d. There is no documentation of physician notification.
Plan of Correction:	Intensive Plan of Correction Required.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based upon review of resident's medication administration records, the facility failed to ensure all required documentation is included in the MAR. EVIDENCE: 1) Resident A has the following order: Hydromorphone 2mg-Take one tablet by mouth every 4 hours as needed for pain, chest pain or shortness of breath. a. Documentation in the MAR indicates medication was administered and was not effective on 02/04/20 at 8:25pm; 02/07/20 at 10:44pm; 02/11/20 at 5:00pm, 02/12/20 at 8:36pm; 02/13/20 at 8:44pm; 02/15/20 at 4:21pm; 02/17/20 at 8:13pm; 02/18/20 at 8:56pm; 02/20/20 at 11:29pm; 02/21/20 at 8:55pm; 02/22/20 at 8:17pm; 02/23/20 at 3:36am; 02/24/20 at 8:18pm; 02/25/20 at 8:08pm ; 02/26/20 at 8:06pm; 02/27/20 at 12:21pm; 02/27/20 at 5:07pm; 03/12/20 at 8:40pm and 03/15/20 at 8:41pm. b. Documentation on 02/20/20 at 11:29pm indicates medication has not helped and he would like the RMA to check with him when he is able to have another dose. There is no documentation of follow-up with resident or physician notification in the MAR for 02/20/20 or for any of the above listed dates and times as it relates to ineffectiveness of medication. 2) Resident A has the following order: Alprazolam 0.25mg-Take one tablet by mouth every 6 hours as needed for anxiety. a. Documentation in the MAR indicates medication was administered on 02/23/20 at 3:38am. Results documented on 02/23/20 at 6:50am indicate medication was not effective.
Plan of Correction:	Intensive Plan of Correction Required.