VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Elms of Lynchburg
2249 Murrell Road
Lynchburg, VA 24501
(434) 846-3325

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: July 29, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION.

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 07/29/2020 and concluded on 07/31/2020. A complaint was received by the department regarding allegations in the areas of resident care and related services. 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. A discussion was held between the Administrator and the LI regarding best practices for writing the facility's medication management policy. The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based on record review, the facility failed to implement methods to ensure that medication orders were accurately transcribed to the medication administration record (MAR) within 24 hours of receipt of a change in an order and failed to ensure that the medication management policy includes all required components. EVIDENCE: 1. The facility?s current medication management policy ?The Elms of Lynchburg Medication Management Policy? states on page 3 that ?Any new changes in medication orders or treatment orders will be noted in the 24-hour report sheet?. 2. The signed physician?s order ?CENTRA PACE DOCTORS ORDER SHEET?, dated 07/15/2020, showed the following: ?3. d/c Lexapro 10 mg?. 3. The July 2020 medication administration record (MAR) for resident 1 showed documentation that Lexapro (escitalopram oxalate) tablet 10 mg 1 TAB PO QD FOR DEPRESSION was administered once a day on the following dates: 07/16/2020, 07/17/2020, 07/21/2020, 07/22/2020, 07/23/2020, 07/24/2020, 07/25/2020, 07/26/2020 and 07/27/2020 and twice a day on 07/20/2020. 4. Interview with staff 1 revealed that it was verified with the pharmacy that the 11 doses of the medication were not administered to the resident and was a documentation error. 5. The facility?s current medication management policy ?The Elms of Lynchburg Medication Management Policy? does not include methods to ensure that staff who are responsible for administering medications will receive periodic direct observation of medication administration. Interview with staff 1 on 07/31/2020 revealed that this was accurate.
Plan of Correction:	1. A new "bucket" system will be added in processing new orders that will include a triple check procedure on new orders ensuring they are properly documented in the EMAR system within a 24hr time frame. As another level of prevention, the Pharmacy will begin packaging medications in a bubble pack system wherein each medication can be scanned to ensure registered medication aides are following the current physician orders. 2. ED added to the Medication Management Plan that, not just new registered medication aides as stated in the plan, all registered medication aides will be adequately supervised which will include periodic direct observation of medication administration by the ED, Director of Resident Care or designee.