VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Journeys Crossing
102 N. Stuart Avenue
Elkton, VA 22827
(540) 298-0054

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: April 23, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

1) Review Tylenol dosage and times of administration for resident A. 2) Ensure all BP and BG and Insulin orders include parameters as when to notify the physician.

Comments:

A focused monitoring inspection was completed in response to communication received from the facility on 04/23/20 indicating medication mismanagement. April medication administration records were reviewed for a selected number of residents. Three staff records were reviewed. There were five violations resulting from this inspection. Details of non-compliance can be viewed in the violation notice section of this report. If you have any questions, please contact the licensing inspector at (540)332-2330 or email rhonda.whitmer@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-280-A
Description:	Based upon review of residents' records and communication with the administrator, the facility failed to have staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with this chapter. EVIDENCE: 1) Based upon review of facility schedule and communication received by the administrator, there were three staff working on 04/19/2020 for second shift; two direct care staff and a registered medication aide. a. The medication variance report indicates medications for 14 residents were not administered at scheduled times of 5:00pm and 6:00pm. b. Documentation indicates "Late, had an emergency to tend to." c. The medication variance report shows medications were administered to the 14 residents between the hours of 7:23pm and 9:35pm. d. Details of residents and medications can be viewed in 22-VAC-40-73-680D.
Plan of Correction:	The Regional Administrator will complete a medication refresher including review of Medication Management Plan, time management, and proper administration of medication with the Facility Administrator and all RMAs. The Regional Administrator will complete a medication refresher including review of Medication Management Plan, time management, and proper administration of medication with the Facility Administrator and all RMAs.
Standard #:	22VAC40-73-450-C
Description:	Based upon review of resident's record, the facility failed to ensure all assessed needs are included in the Individualized Service Plan. EVIDENCE: 1) The ISP for resident N (admitted 03/13/20; Discharged 04/23/20) indicates mechanical and physical assistance is needed with dressing. The ISP indicates physical assistance. a. The UAI indicates that resident's behavior is appropriate. The ISP indicates resident occasionally refuses care, yells, smacks and scratches and staff will re-direct to the best of their abilities. b. The UAI indicates resident is disoriented to some spheres all of the time. Spheres affected are not identified on the UAI. The ISP does not identify spheres affected or any interventions for the resident. c. The ISP does not contain signature of person completing the plan or the signature of the resident or legal representative.
Plan of Correction:	Facility Administrator and the Regional Administrator will review all UAIs for completeness, correctness, and that the UAI and ISP match. The ?double check? process will continued to be completed on all future UAIs for new admissions, yearly reviews, or significate changes by the Facility Administrator and her designee.
Standard #:	22VAC40-73-640-A
Description:	Based upon the review of the medication management plan,the facility failed to implement and monitor procedures within the written plan for medication administration. EVIDENCE: 1) The facility medication management plan indicates a review of the Electronic Medication Administration Record (EMAR) shall be performed bi-monthly to ensure accurate and complete documentation (to include timely documentation of effectiveness of PRN medicaitons) 2) The medication management plan indicates for changed orders, the medication aide will get the order and verify that the order and EMAR match and this should be done within 24 hours of receipt. If the medication aide agrees, the order will be merged , the date and initials wrote on order and the order will be placed in the filing bin. If the order and EMAR does not match, the medication aide will contact the pharmacy for clarification. If the order and EMAR still do not match, contact the nursing director and the medication aide will communicate change at the end of shift reporting. 3) The medication management plan indicates if there are discrepancies and concerns, the medication aide will call the pharmacy and communicate the problem/concern. 4) The medication management plan indicates if a medication is not available at the scheduled time of administration, the responsible party will be notified, a Medication Unavailable form will be completed and put in the administrator box and the supervisor will be notified. Charting "med not available" on the EMAR alone, does not fulfill this requirement. The medication aide will communicate unavailable medications to the physician and at end of shift reporting.
Plan of Correction:	The Facility Administrator and all RMAs will review the Medications Management Plan. 1. The Administrator or designee will document a bi-monthly review to assure accurate and complete documentation to include PRN medication and effectiveness. 2-4. The review of plan will include how to process new change, and discontinued orders, complete forms and what to do if items does not match.
Standard #:	22VAC40-73-680-D
Description:	Based upon review of residents' records and communication from the administrator , 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 O had the following order: Morphine Sulfate 20mg/ml: Give 0.25ml (0.5mg) by mouth every hour as needed for pain/dyspnea. a. Documentation in the MAR indicates medication was administered on 04/21/20 at 4:33pm and 5:20pm by staff C. 2) Resident O has the following order: Morphine Sulfate 20mg/ml: Give 0.5ml every hours as needed for pain/dyspnea. a. Documentation in the MAR indicates medication was administered on 04/23/20 at 12:24am and 1:20am and on 04/23/20 at 3:32am and 4:30am by staff B. 3) Resident O had an order for comfort pack medications effective 04/17/20 from hospice that included Acetaminophen suppositories, Bisacodyl suppositories, Hycoscymine tablets, Senna tablets and Phenergan tablets. a. Documentation in the Electronic MAR indicates on 04/19/20 staff A discontinued Bisacodyl suppositories at 4:56pm, Hyoscyamine tablets at 4:58pm, Promethazine at 4:59pm, and Senna at 5:00pm. b. Per communication received from the administrator on 04/23/20, a discontinue order was not received from the physician. c. Per communication received from the administrator on 04/23/20, resident was in need of Hyoscyamine on 04/23/20 due to increased secretions. d. Comfort pack medications were still in the facility. Staff B did not administer Hyoscyamine. e. Per documentation, staff B contacted the hospice agency, but nurse did not come to the facility. f. Resident passed away at 5:30am on 04/23/20. 4) Communication from the administrator on 04/23/20, indicates medications scheduled for 5:00 & 6:00pm were administered late by staff A on 04/19/20. 5) Upon review of the medication variance report, the following residents did not receive their scheduled medications. The report indicates medications missed were administered between 7:23pm and 9:35pm. a. Acetaminophen, Atorvastatin and Famotidine are scheduled at 6:00pm for resident A. Medication variance report indicates these were administered at 9:10pm. The Acetaminophen order indicates times of administration as 8:00am, 12:00pm, 6:00pm and 8:00pm. The MAR indicates the 8:00pm dose was administered. b. Resident B has Sertraline scheduled at 6:00pm. The report indicates this was administered at 9:17pm. c. Resident C has Artificial tears, Famotidine, and Salonpass Gel to be administered at 6:00pm. The report indicates these were administered at 9:35pm. The MAR indicates the Artificial tears and Salonpas are also to be administered again at 9:00pm. The MAR indicates both were administered at 9:00pm. d. Resident D has an order for Mighty Shake to be given at 6:00pm. The report indicates this was given to resident at 9:15pm. Resident D also has an order for Mesalamine due at 5:00pm . Documentation in the MAR indicates resident refused the medication at 9:15. *Resident D also has the following order effective 04/03/20: TED stockings to be on in the morning and off in the evening for bilateral lower edema. *Documentation in the MAR indicates these were not available to the resident from the time order was written through 04/21/20. *Communication from pharmacy on 04/17/20 indicates item is out of stock and has been ordered for next day's delivery and also indicates ETA Delivery is 04/21/20 through 04/24/20. *Resident D has an order for Mesalamine to be taken twice a day. Documentation in the MAR indicates resident refused on 04/10, 04/16, 04/18 and 04/19. There is no documentation of physician notification. **Due to the volume of information gathered during this inspection, a separate document has been created**
Plan of Correction:	The Facility Administrator or Designee will review all current orders to assure all information required as outlined in the current registered medication aide curriculum is correct and current. This will be completed by 05/29/20. The Regional Administrator will complete a medication refresher including review of Medication Management Plan, all information required as correct orders, how to check when the last PRN medication is given to assure that the correct time frame is followed, how to check chart for orders, remind of time frame of one hour prior to one hour after, and when to contact the administrator on call. This will be completed by 05/18/20. All new, changed, or discontinued orders will be kept in a file folder labeled awaiting for Facility Administrator?s & Regional Administrator?s initials.Then filed in resident charts. This will be completed by 05/14/20. The Facility Administrator will check orders by the next working day as a ?double checking? system to assure correctness in order, properly transcribed on eMARS, and that medications, eMARS, and order match , and medications exceptions forms for 8 weeks, then weekly for 8 weeks, the bi-monthly as indicated in the Medication Management Plan. The Facility Administrator will initial the orders. These checks will be documented and logged. The Regional Administrator will ?spot? check the log for current documentation and document.This will be completed 05/14/20 through 09/11/20. The Regional Administrator will check the file folder weekly, to assure correctness in orders, properly transcribed on eMARS, and that medications, eMARS, and order match , and medications exception forms for 8 weeks, then bi-monthly for 2 months. These checks will be documented and logged. The Regional Administrator will initial orders then put in the filing folder to be filed.This will be completed 05/14/20 through 08/22/20. The regional administrator will initial the orders. These checks will be documented and logged. Any issues will be addressed at time of discovery. This will be completed by 05/11/20.
Standard #:	22VAC40-73-680-I
Description:	Based on review of residents' records, the facility failed to ensure the Medication Administration Record (MAR) contains all required information. EVIDENCE: 1) The MAR for resident B indicates Morphine was administered on 04/02/20 at 11:04am. Documented results indicate "resident states it did not help." a. There is no documentation of follow-up. 2) The MAR for resident B indicates Lorazepam was administered on 04/18/20 at 2:45pm. Documented results indicate "resident still yelling." a. The MAR indicates resident was administered Morphine at 3:20pm. Documented results indicate "resident still yelling. b. There is no documentation of follow-up. 3) The MAR for resident C indicates Tylenol was administered on 04/19/20 at 12:08pm due to resident having a low grade temperature of 99. Documented results indicate "temperature is within normal range." a. There is no documentation of temperature post administration of Tylenol. 4) Resident F has the following order: Metoprolol SC ER 25mg-Take 1/2 tablet by mouth everyday. Hold for heart rate less than 60. a. There are no initials of staff or documentation of heart rate on 04/17/20. 5) Resident G has the following PRN order: Novolog 100U/ML Vial-Inject subcutaneously per sliding scale with meals for blood sugar 400-450=4 units; 451-500=6 units; greater than 500=8 units. a. Documentation indicates resident's blood sugar was 406 on 04/20/20 at 5:00pm. b. Documented results indicate "normal bs." c. There is no blood sugar documented post administration. 6) Resident I has the following PRN order: Clonidine 0.1mg take one tablet by mouth twice per day as needed for systolic blood pressure over 165. a. Documentation in the MAR indicates medication was administered on 04/01/20 at 6:50am due to BP of 180/73. Documented results indicate "resident's BP within normal range." There is no blood pressure documented post administration. b. Documentation in the MAR indicates medication was administered on 04/16/20 at 8:17am due to BP of 180/84. Documented results indicate "resident's BP came down." There is no blood pressure documented post administration. c. Documentation in the MAR indicates medication was administered on 04/28 at 7:12am due to BP of 196/109. Documented results indicate "it lowered BP." There is no blood pressure documented post administration. d. Documentation in the MAR indicates medication was administered on 04/29/20 at 8:42am due to BP of 182/90. Documented results indicate "BP was lowered." There is no blood pressure documented post administration.
Plan of Correction:	The Regional Administrator will complete a medication refresher including review of Medication Management Plan and proper documentation and notifications needed for PRN results with the Facility Administrator and all RMAs. This will be completed by 05/18/20. The Facility Administrator will check the PRN log for correctness by the next working day for 8 weeks, then weekly for 8 weeks, the bi-monthly as indicated in the Medication Management Plan. These checks will be documented and logged. The Regional Administrator will ?spot? check the log for current documentation and document.This will be completed 05/14/20 through 09/11/20. The Regional Administrator will check the PRN log for correctness weekly for 8 weeks, then bi-monthly for 2 months. These checks will be documented and logged. This will be completed 05/14/20 through 08/22/20. Any issues will be addressed at time of discovery.