VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Cedar Bluff
500 Clinic Drive
Cedar bluff, VA 24609
(276) 596-9750

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: Jan. 14, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS

Comments:

Two licensing inspectors conducted a focused monitoring visit regarding a self-reported incident at Commonwealth Senior Living at Cedar Bluff on 01/14/2020. The monitoring inspection began at 2:00 pm and concluded at 2:45 pm. The licensing inspectors observed the interior and exterior of the building, resident rooms, resident records, and interviewed a resident and staff. An exit meeting was held with the administrator of the facility on 01/14/2020. Two violations are being cited as a result of this monitoring inspection. An Intensive Plan of Correction (IPOC) meeting has been scheduled on 02/20/2020 at 10:00 am. Please sign these documents and return to your inspector. If you have any questions or concerns please contact your licensing inspector at 276-608-1067. Thank you for your cooperation and assistance in this matter.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on review of a resident file, the facility failed to ensure that the physical examination prior to admission included all of the required documentation. EVIDENCE: 1. The physical for Resident #1 was dated 12/30/2019. The physical did not include the resident's diagnosis or significant problems.
Plan of Correction:	Resident #1 History and Physical was updated to include significant problems. ED or designee to audit charts for significant problems on History and Physicals, and ensure on new admissions, updates or change in status and ongoing. [sic]
Standard #:	22VAC40-73-460-A
Description:	Based on staff interviews, collateral interviews and documentation review, the facility failed to assume general responsibility for the health, safety, and well-being of one resident in care. EVIDENCE: 1. According to the Uniform Assessment Instrument (UAI) dated 01/02/2020 for Resident #1 walking is not performed, physical assistance is required for mobility purposes, and mechanical help is required when wheeling. 2. The assessment for cognitive impairment dated 12/30/2019 has "NO" checked when asked "Is the individual named above unable to recognize danger or protect his/her own safety and welfare?". On the physical examination dated 12/31/2019 the box is checked stating "Non-ambulatory (by reason of physical or mental impairment is not capable of self-preservation requiring the assistance of another person)." These are conflicting statements. 3. The weather for 01/07/2020, was high of 36 degrees, low of 31 degrees, according to weather.com. Staff #1 stated there was snow on the ground and it was cold outside. Resident # 1 was discovered outside and according to the scene information on the dispatch report, patient was found about 70 feet down and over to the left about 30 feet and 25 feet before the edge of a cliff that went to Food City below. The resident was found on the ground, with his wheelchair located nearby. Facility nursing notes state that at 6:00 am Resident #1 was observed to be sitting in the common area, at 6:10 am, the security camera shows Resident #1 getting into his wheelchair and heading toward the side exit door. At approximately 6:45 am two employees from a grocery store located in a shopping center below the facility came to the facility to inform the staff that they heard a person calling for help in the back of the building. The grocery store employee had already called 911. The rescue squad arrived and the responding Emergency Medical Technician (EMT) stated the night shift employees at the facility informed him that they noticed Resident #1 had tried to leave around 1:00 am, and he was redirected. The EMT stated that facility staff informed him they were busy with another patient and wasn't paying attention when Resident #1 made his way out of the facility. According to an interview with the Emergency Medical Technician (EMT) that responded to the scene, Resident #1 was found on the ground, his skin was cold to the touch, and he had a small laceration to to the left side of his head. The responding EMT placed blankets on the resident. After the resident was secured and removed from the scene the EMT placed hot packs on the resident and obtained vital signs. Resident #1 had a tympanic (temperature taken in the ear) temperature of "92 point something", tympanic temperatures are usually half to one degree higher than an oral temperature. Resident #1's blood pressure was documented at 154/98. The EMT gives a field diagnosis of hypothermia. Resident #1 was found dressed in a long sleeve shirt, sweat pants and one shoe on. 4. Resident #1 was seen in the emergency room on 01/07/2020 due to a fall and was assessed as follows: blood pressure: 141/69, respiratory rate: 20, temperature: 97.4 and he was noted as slightly delirious, a very poor historian, and experiencing dementia. He was admitted to the hospital on the same date and diagnosed with acute cellulitis of the right ankle with sepsis due to the swelling and extreme redness. 5. Resident #1 remained in the hospital for five days (01/07/2020-01/12/2020) and was discharged back to the facility on 01/12/2020.
Plan of Correction:	Resident #1 was readmitted from CVMC with no residual effects related to incident. Camera system moved to show all exit angles on 02/15/2020, door alarms were installed on 03/20/2020 on each exit door of the community. Executive Director did an audit on all history and physical exams for conflicting statements. Completed on 07/20/2020. Saff in-service on change of condition policy and alert charting policy. [sic]