VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brightview Great Falls
10200 Colvin Run Road
Great falls, VA 22066
(703) 759-2513

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: June 16, 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 6/15/2020 and concluded on 6/16/2020. A self-reported incident was received by the department regarding allegations in the areas of medication administration. The administrator was contacted by email 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 supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice. 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 e-mail at jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based upon a review of resident records and information provided by administration, the facility failed to ensure that medications shall be 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: On 6/13/2020 during the 8:00 am medication pass, Resident #1 received the following medications that were prescribed for another resident: 10mg Memantine; 20mg Escitalopram; 10mg Donepezil; 100mg Celecoxib; and 0.25mg Xanax.
Plan of Correction:	Nurse was re-educated on standards of practice for medication administration, including specific focus on ensuring medications are given to the "right person." Nurse was immediately observed passing medications to ensure all medication administration practices were followed properly. Nurse finished the shift on 6/13/2020 and did not return for future shifts. Director or designee to re-educate nurses and registered medication aides on medication administration practices, with specific focus on practices that ensure medications are given to the right resident. Medication pass observations will be completed quarterly for each nurse and medication aide to ensure practices are being followed according to the Virginia Board of Nursing standards of practice as well as company practices related to medication administration. Corrective action will be initiated for any variances and findings will be reported to the Executive Director. Person responsible: Health Services Director or designee.