VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brightview Woodburn
3450 Gallows Road
Annandale, VA 22003
(703) 462-9998

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: June 1, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on May 22, 2020 and concluded on June 1, 2020. A self-reported incident was received by the department regarding allegations in the areas of medication administration and medication management. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via email at jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based upon a review of resident's records and interview with administration the facility failed to implement a written plan for medication management for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order. Evidence: The medication administration record (MAR) for Resident #1 was inaccurately transcribed when Magnesium Ox Tab 400mg was added to the MAR without a valid order from a physician or other prescriber.
Plan of Correction:	The Wellness Nurse who approved the incorrect order in Quick MAR was counseled and re-educated on 5/22/20. All nurses re-educated on order approval process as outlined on the Resident Care Order policy by 6/30/20. Resident care order policy reviewed and updated to include additional steps to ensure orders are approved and then confirmed by a second nurse by 6/30/20. Health Services Director will audit all resident care orders to monitor compliance for the next 8 weeks and based on results modify or discontinue the audit. The pharmacy also implemented a plan of correction on 5/27/20 that included a pharmacy policy review with the pharmacist involved in the error and a daily audit of all voided prescriptions to ensure all steps are completed to prevent this error from occurring in the future. The pharmacist was retrained on 5/22/20 and a daily review of the `void report? was initiated on 5/25/20 and will continue as on-going. The pharmacy?s quality assurance department will provide a weekly summary of all VOID activities and identify any staff not following policy. A weekly review with administrative pharmacy staff was initiated on 6/1/20 and will continue as on-going.
Standard #:	22VAC40-73-650-A
Description:	Based upon a review of resident's records and interview with administration, the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications. Evidence: Resident #1 received 11 dosages of Magnesium Oxide Tablet 400mg between May 16, 2020 and May 21, 2020. Resident #1 did not have a physician's or other prescriber's order for Magnesium Oxide Tablet 400mg.
Plan of Correction:	The Wellness Nurse who approved the incorrect order in Quick MAR was counseled and re-educated on 5/22/20. All nurses re-educated on order approval process as outlined on the Resident Care Order policy by 6/30/20. Resident care order policy reviewed and updated to include additional steps to ensure orders are approved and then confirmed by a second nurse by 6/30/20. Health Services Director will audit all resident care orders to monitor compliance for the next 8 weeks and based on results modify or discontinue the audit. The pharmacy also implemented a plan of correction on 5/27/20 that included a pharmacy policy review with the pharmacist involved in the error and a daily audit of all voided prescriptions to ensure all steps are completed to prevent this error from occurring in the future. The pharmacist was retrained on 5/22/20 and a daily review of the `void report? was initiated on 5/25/20 and will continue as on-going. The pharmacy?s quality assurance department will provide a weekly summary of all VOID activities and identify any staff not following policy. A weekly review with administrative pharmacy staff was initiated on 6/1/20 and will continue as on-going.