VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Stratford House
1111 Main Street
Danville, VA 24541
(434) 799-2266

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: April 2, 2020 , April 7, 2020 and April 8, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

On 4/2/2020, 4/7/2020, and 4/8/2020 one inspector conducted an unannounced focused inspection in response to a self-reported incident involving an elopement. The inspection was conducted via review of scanned/emailed documentation and telephone interviews. An exit interview was conducted via telephone with the Administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. 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 #:	22VAC40-73-460-D
Description:	Based on documentation and interviews, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs such as wandering off the premises. EVIDENCE: 1. A self-reported incident sent on 3/26/2019 described how resident 1, who resides in the special care unit of the facility, eloped without staff knowledge and was brought back to the facility by the police. The incident report described how tapes of the entry area to memory care and the main building entrance were reviewed after resident 1 was returned. The following information was discovered: Resident 1 left the memory care unit at 1:51 PM on 3/25/2020 by the memory care entrance after an employee exited and before the magnetic lock engaged again. Resident 1 left the building at 1:52PM on 3/25/2020 from the main entrance while the concierge was in the copy room located behind the desk that overlooks the entrance door. Police returned the resident to the facility at approximately 4PM on 3/25/2020. The incident report described how a staff person falsely documented that the resident was seen and monitored while resident 1 was actually out of the building. 2. The Administrative Notes dated 3/26/2020 showed that resident 1 was seen outside the facility at 3:06 PM by an unknown person; the police were called and resident 1 was picked up by them approximately ? mile away from the facility at 3:15 PM. Phone interview with the Administrator revealed that the resident was first sighted at 3:06 PM farther away from the facility than ? mile. 3. The Administrator was interviewed by phone and confirmed the information on the incident report. On 4/8/2020 the Administrator was again interviewed by phone and it was established that the resident was wearing long pants, and a long sleeved knitted top. 4. Resident 1 has a serious cognitive impairment, as documented on the ASSESSMENT OF SERIOUS COGNITIVE IMPAIRMENT FORM signed by a physician on 5/22/2018. 5. The uniform assessment instrument (UAI) dated 4/9/2019 for resident 1 showed this resident has wandering behavior and is disoriented to time some of the time. 6. The individualized service (ISP) dated 4/9/2019 showed resident 1 is unable to leave the premises without assistance, wanders frequently, and is re-directed, is disoriented to time and will be re-oriented as needed, resident resides in a secure unit due to dementia and MD order, will have frequent safety checks, lives in a safe, secure environment. 7. The weather was dry and partly sunny with temperatures between 52F and 63F while resident 1 was missing from the facility. This was confirmed by checking the following website: https://www.timeanddate.com/weather/@4755280/historic?month=3&year=2020 8. A telephone interview and email communication with collateral 1 on 4/8/2020 revealed that there was no police report made on the incident.
Plan of Correction:	What Has Been Done to Correct? The resident was returned to the community safely. Community cameras were reviewed to determine exactly how the elopement occurred. The associate who did not monitor the closing of the secured door was given a written final notice. The associate who falsified documentation about a safety check was terminated. Staff were in-serviced on Mag lock security, two hour checks in Memory Care, and shift walk-throughs. The closure on the doors were checked and adjusted for the time delay on closing. All mag locks were checked for security. How Will Recurrence Be Prevented? The ED and or designee will continue to do training with all staff and new hires on security in Memory Care. Maintenance staff will randomly check secured doors to ensure that they are functioning as designed. The ED and or designee will ensure that appropriate Elopement drills are in place. Person Responsible: ED and or designee, Maintenance Director