VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Pearl at Watkins Centre
650 Watkins Centre Parkway
Midlothian, VA 23112
(804) 893-0067

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: March 10, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A complaint investigation was initiated at the facility on 3/10/2020 during an unannounced inspection in regards to resident care and supervision. Based on a review of file documentation and facility photographs, the complaint is determined to be valid. Please complete the "plan of correction" and "date to be corrected" for the violation cited and return to the Inspector within 10 days. 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: 1) steps to correct the non-compliance with the standard, 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). See violation notice for non-compliance

Violations:

Standard #:	22VAC40-73-460-B
Complaint related:	Yes
Description:	Based on interviews with staff, photographs and a review of nursing notes, the facility failed to ensure that care provision and service delivery is resident-centered to the maximum extent possible including prompt response by staff to resident needs as reasonable to the circumstances. Evidence: According to the documentation reviewed and provided by the facility, the call bell was activated by resident # 1 at 7:34 am after a fall in her room. 1.The resident reported that there was no response to the call bell activation, so she got herself up from the floor, went to the dining room and reported the fall to staff. 2. The facility reported that staff did respond to the call bell, that the staff responding met the resident in the hallway and accompanied the resident to the dining room. Security system photographs were submitted as evidence. 3.The photographs submitted as evidence did not show any staff with the resident. 4. The photographs did show the resident entering the dining room at 7:48 am. unaccompanied by staff. 5. There was no documentation provided to show that staff responded to the call bell from 7:34 am to 7:48 a.m.
Plan of Correction:	While the resident was approached in the hallway by a Resident Care Aide, her pendant was not appropriately reset by the associate. The staff member stated that she had pressed the pendant to reset it-and multiple presses were logged, but it did not deactivate the call. The resident did not report having a fall to staff in the dining room or to the RCA who checked on the resident, but once the family notified the Wellness Director of the resident having a fall, the resident was assessed and a follow up was provided promptly to the family. The Plan of Correction is to in-service all staff on how to appropriately reset a pendant worn by a resident, as well as a comprehensive review of the Call Bell Procedure. In-Services will be provided to all staff members on how to reset pendants properly by the Facilities Director, as well as to a Comprehensive Call Bell Procedure Review with both the Wellness Director and Executive Director by Wednesday, April 1st, 2020. Call Bell/Pendant Logs will be pulled and reviewed at least daily by both the Executive Director and Wellness Director to ensure proper response times are always being maintained .