VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bickford of Virginia Beach
2629 Princess Anne Road
Virginia beach, VA 23456
(757) 821-0198

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: June 12, 2020 , June 15, 2020 , June 16, 2020 and June 17, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

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 complaint inspection was initiated on 06-12-2020 and concluded on 06-17-2020. A complaint was received by the department regarding allegations in the areas of Resident Care and Related Services and Buildings and Grounds. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law.

Violations:

Standard #:	22VAC40-73-40-A
Complaint related:	No
Description:	Based on record review and interview, the licensee failed to ensure compliance with the facility?s policies and procedures. Evidence: 1. On 04-23-2020, staff #1 emailed an incident report involving resident #2, which documented ?On April 15, at 1:30 p.m., the above Memory Care resident was preparing to sit in a dining room chair, turned his walker around, lost his balance, and fell backwards landing on his bottom and right side?? 2. The staff ?Progress Notes? dated 03-05-2020 documented resident #2 ?had an unwitnessed fall? Laceration noted to middle of head.? Resident was sent to the emergency room and was noted to have 8 staples to laceration on head. 3. Staff #1 provided a copy of the facility?s policies and procedures labeled ?Incident and Accident Report? which documented ?Resident or Bickford Family Member incidents or accidents are to be reported and documented immediately after they occur. Incidents or accidents can include but are not limited to resident falls or injuries? Incidents or accidents shall be documented on the Bickford Incident Report form immediately following the occurrence. Bickford Family Members shall also complete the top portion of the Fall Investigation Tool Immediately after a Resident fall. The RN Coordinator shall complete the bottom portion of the Fall Investigation Tool within 24 hours after each Resident fall, or the next work day?? 4. When asked to provide documentation of the ?Bickford Incident Report? regarding resident #2?s aforementioned falls, staff #1 provided forms labeled ?Unusual Occurrence Nursing Evaluation? and ?Fall Risk Assessment.? A.The ?Unusual Occurrence Nursing Evaluation? documented the ?Date of Occurrence? 03/05/2020, and was signed and dated by staff #2 (RN Coordinator) on 03/09/2020. The ?Fall Risk Assessment? was signed and dated by the staff #2 on 03/09/2020. B. The ?Unusual Occurrence Nursing Evaluation? documented the ?Date of Occurrence? 04/15/2020, and signed and dated by staff #2 on 04/17/2020. The ?Fall Risk Assessment? was signed and dated by the staff #2 on 04/17/2020. 5. During interview, staff #1 and staff #2 acknowledged the ?Bickford Incident Form? was not documented immediately after resident #2?s aforementioned falls and the ?Fall Investigation Tool? was not completed within 24 hours after each fall per the facility?s ?Incident and Accident Report? policies and procedures.
Plan of Correction:	*Bickford of Virginia Beach policy on ?Incident and Accident Report? was amended to now include the Assistant Care Coordinator in the completion/documentation of all aspects of the incident and accident reporting process. * The revised policy was reviewed with the Registered Nurse Coordinator, the Assistant Care Coordinator, and those with appropriate credentials functioning in their absence or as interim/acting.
Standard #:	22VAC40-73-680-H
Complaint related:	No
Description:	Based on record review and interview, the facility failed to document on the Medication Administration Record (MAR) all medications administered to residents at the time the medication is administered. Evidence: 1. Resident #1?s verbal physician?s order dated 01-18-2020 (signed and dated by the physician on 01-20-2020) documented ?Cipro 500mg PO [by mouth] BID [twice daily] x5 days- DX UTI.? The January 2020 MAR documented the Cipro 500mg was scheduled to be administered at 8:00 AM and 8:00 PM. Staff administered the Cipro 500mg to resident #1 on 01-20-2020 (8:00 PM dose only), 01-21-2020, 01-22-2020, and 01-23-2020 (8:00 AM dose only). The MAR did not document the resident received Cipro 500mg twice daily for 5 days per the physician?s instructions. 2. Staff #1 indicated that staff completed a paper MAR for the first few Cipro 500mg doses; however, staff #1 stated ?I have looked for the paper MAR? but I am unable to locate it at this time.? 3. Staff #1 provided a copy of the facility?s ?Medication Administration? policy which documented ?? Document in the Medication Administration Record (MAR) immediately after the administration of medication by initialing in the appropriate time slot?? 4. Staff #1 acknowledged staff did not document on resident #1?s MAR at the time the Cipro 500mg was administered.
Plan of Correction:	*Resident #1 has been discharged from the community. *An MAR binder will be utilized, for organizational purposes, for any resident who requires a paper MAR in lieu of the electronic MAR for documentation of medication administration. *At the end of each month, any paper MARs utilized during that month will be transferred from the MAR binder into the resident?s medical record for proper retention. *All RMAs will be trained on the new process regarding the proper utilization and storage of paper MARs.