VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Fork Mountain Adult Home
2925 Fork Mountain Road
Rocky mount, VA 24151
(540) 483-8800

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: March 20, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A complaint was investigated regarding an allegation that a resident was injured and the facility did not immediately seek medical attention. Another agency was involved with the investigation. The preponderance of evidence supports the allegation. The complaint is valid. Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must contain the following: 1) steps to correct the noncompliance with the standard(s); 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). If you have any questions, please contact your licensing inspector at 540-309-3043

Violations:

Standard #:	22VAC40-73-470-F
Complaint related:	Yes
Description:	Based on document review, the facility failed to obtain immediate medical attention from a licensed health care professional after a resident suffered an injury. EVIDENCE: 1. Facility and staff documents show an incident happened to resident 1 at approximately 7:30PM on 12/21/2019 and despite screaming, was not sent for medical care until approximately 1PM on 12/22/2019. 2. Hospital documents dated 12/22/2019 showed that resident 1 was at the hospital and was diagnosed with closed fracture of proximal end of right femur. [broken leg] 3. An incident report regarding resident 1, completed by staff 1, showed that on 12/21/2019 at 7:30PM staff 1 was "putting resident to bed when turning her to sit in bed patient state it hurt her leg - not sure what happened - kept complaining so sent to ER at 1:00AM". 4. A written statement from staff 2 stated that resident 1 was screaming and hollering the whole time while staff 1 was putting resident 1 to bed, and after that. Staff 2 went to check on resident 1, who told her that "the woman that put her to bed twisted and twisted her leg" and that it hurt. Staff 2 also notes that while resident 1 hollers a lot, it was much worse this time. 5. A written statement from staff 3 stated that she came to work at 11PM. She noted that around 11:30 resident 1 was screaming and when staff 3 checked on her, she was complaining about her leg hurting and stated "The lady did something to her leg she couldn't remember her name but her leg leg [sic] hurt like the devil". Resident 1 was still screaming 30 to 45 minutes later. Staff 3 noted the right leg was a little swollen and slightly bruised. The statement continues (names have been replaced with numbers): "I went to staff 1 and told her resident 1 needed to go to the ER. Staff 1 said "If she was sent out they would question the bruise on her arms. Then when getting paperwork together - she aske [sic] what she should say happen. Prior to her agreeing to send her out I had told staff 1 if she didn't make the call to send resident 1 out I would. Resident 1 left Fork Mountain around 1AM." "Resident 1 woke up 3 resident screaming." "Staff 1 stated that if she sent her out they would think she done something to her." "Staff 1 was asking me what to say for sending her out". 6. A written statement from staff 4 dated 1/24/2020 showed that resident 1 stated her leg was twisted when she was being put to bed. Staff 4 told staff 1 that resident 1 might need to go to the E.R. cause if not she would not be getting rest. 7. A written statement from staff 5 stated that staff 5 was not working the night resident 1 broke her leg, the staff 5 put resident 1 to bed the prior night, 1/20/2020, and had no complaints of leg pain.
Plan of Correction:	See attached documented meeting with staff & in-service. "An in-service was conducted on March 25, 2020 on Adult Abuse involving all employees of Fork Mountain Adult Home. All employees of the 3-11 shift signed another Organizational Chart. This served as a reminder of the chain of command when an incident occurs at the facility and who to contact when there is an issue. Effective immediately on all shifts any resident in a wheelchair will now be required at all times to have a two man transfer from the wheelchair to any other location. The employees were reminded they are here to serve all the residents of the facility not just certain ones. If an employee feels that another employee is not pulling their weight on a particular shift, they first need to ask that staff member for additional assistance. If that does not seem to resolve the matter they need to speak with [the administrator] about the issue. When an incident occurs during a shift and the administrator is not present, the person in charge is responsible for conducting the entire assessment of the resident. It is the responsibility of the person in charge to then contact the administrator by calling her phone, not via text. If another employee of the facility feels the person in charge is not handling the situation properly it is your responsibility to call the administrator on her cell phone to address your concerns/ If an any point a resident falls and verbalizes they are in pain the person in charge is required to send the resident to the hospital for assessment, to contact the administrator and then to contact family and let them know what has taken place."