VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Emily Green Shores
500 Westmoreland Avenue
Portsmouth, VA 23707
(757) 399-3442

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: June 10, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 EMERGENCY PREPAREDNESS

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 renewal inspection was initiated on 06-10-2020 and concluded on 06-10-2020. The Resident Care Director was contacted by telephone to initiate the inspection. The Resident Care Director reported that the current census was 23. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, criminal background checks and sworn disclosures of newly hired staff, staff schedules, fire drills, fire and health inspection reports, dietary oversight, and healthcare oversight. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-440-A
Description:	Based on resident record review and interview, the facility failed to ensure the Uniform Assessment Instrument (UAI) was completed whenever there is a significant change. Evidence: 1. Resident #2?s current Individualized Service Plan (ISP) dated 06-10-2019 documented the resident needs assistance with the following: A. Bathing- resident to use ?handrail/shower seat to maintain balance while getting in/out of shower with staff assistance?? B. Toileting- resident to use ?grab bars to assist with transferring safely on/off toilet. Direct Care Staff will assist resident with pulling up/down resident?s clothing if needed...? C. Transferring- resident to use ?arm of chair, locked rollator walker, grab bars, rails to enhance safety during periods of transferring.? 2. Resident #2?s current UAI dated 06-10-2019 documented the resident requires physical assistance with bathing, supervision with toileting, and does not require assistance with transferring. 3. Resident #3?s current ISP dated 07-09-2019 documented the resident needs assistance with bathing- resident to use ?handrail/shower seat to maintain balance while getting in/out of shower. Direct Care Staff will prepare the shower-adjusting the water temp? needs assistance with hair, back, and lower extremities?? 4. Resident #3?s current UAI dated 07-09-2019 documented the resident requires physical assistance for bathing. 5. Staff #1 stated resident #2 and resident #3?s ISP?s were current and that the aforementioned UAI?s were not updated to reflect the resident?s needs.
Plan of Correction:	Administrator/RCC will ensure that the UAI and ISP both reflect any changes in resident care as change of status occurs.
Standard #:	22VAC40-73-620-B
Description:	Based on resident record review and interview, the facility failed to ensure upon receipt of recommendations from the dietary oversight that the administrator, dietitian, or nutritionist report the recommendations to the resident's physician. The documentation of the report was not maintained in the resident's record. Evidence: 1. Staff #1 provided a copy of the dietary oversight dated 02-11-2020. The dietitian documented resident #1 has ?Poor PO [by mouth] intake, weight decreasing? with a recommendation to ?? start nutrition supplement of liking? Start Ensure BID?? 2. Staff #1 could not provide documentation verifying the administrator, dietitian, or nutritionist had reported the dietitian?s recommendations to resident #1?s physician. 3. Staff #1 stated the physician was not notified of the dietitian?s recommendation for resident #1 to receive Ensure due to poor PO intake and weight decreasing.
Plan of Correction:	RCC will review all dieticians' oversite recommendations for residents with the dietician at time of review to ensure physician is notified regarding the recommendations for resident's diet order.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review and interview, the facility failed to ensure medications were administered in accordance with the physician's or other prescriber'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. Staff #1 provided a copy of resident #4?s current signed physician?s orders dated 05-13-2020, which documented ?Novolog 100U/ML Vial- Inject S.C 3 times a day before meals using sliding scale; 140-180 4 units; ? 221-240 7 units; 241-280 8 units; 281-300 9 units? for Diabetes.? 2. Resident #4?s May 2020 Medication Administration Record documented staff administered Novolog insulin during the 12:00 PM medication administration on 05-03-2020, 05-09-2020, and 05-15-2020. 3. Staff #1 provided documentation labeled ?Diabetic Flow Sheet,? which documented the number of units of Novolog insulin administered to resident #4 during the 12:00 PM medication administration for the following blood sugar readings: A. 05/03/2020 ? Blood Sugar (BS) reading was 226 ? 8 units of insulin was administered; which was 1 unit more than ordered by the physician; B. 05/09/2020 ? Blood Sugar (BS) reading was 285 ? 4 units of insulin was administered; which was 5 unit less than ordered by the physician; C. 05/15/2020 ? Blood Sugar (BS) reading was 248 ? 7 units of insulin was administered; which was 1 unit less than ordered by the physician. 4. Staff #1 confirmed the units of insulin administered to resident #4 on the aforementioned dates and times and acknowledged the resident?s Novolog insulin was not administered in accordance with the physician?s instructions.
Plan of Correction:	On 6/18/2020 A.C.T. Pharmacy will conduct a (4) hour refresher course for all Medication Aids and will emphasize the procedure for sliding scale insulin administration during the class. Effective immediately the RCC will monitor the diabetic flow sheet to ensure the physician's orders are being followed as written.