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Cary Adult Home
7336 Cary Avenue
Gloucester, VA 23061
(804) 693-7035

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: Aug. 12, 2020 , Aug. 17, 2020 and Aug. 18, 2020

Complaint Related: Yes

Areas Reviewed:
22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:
This inspection was conducted by licensing staff using an alternative remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia.
The evidence gathered during the complaint investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:
Standard #: 22VAC40-73-470-A
Complaint related: No
Description: Based on document review and staff interview, the facility failed to ensure, either directly or indirectly, that the health care service needs of a resident are met.

Evidence:
1. On July 13, 2020, July 14, 2020 and July 16, 2020 complaints were received regarding resident #1 not receiving appropriate medical care. According to discharge documents and resident?s nurse?s notes, resident #1 was admitted to a local hospital June 23 ? June 26, 2020 and July 15- July 16, 2020.
2. A review of resident #1?s discharge on June 26, 2020, resident instructed to follow-up with physician in 5 days. Further review, the document indicated, resident had not seen the physician listed in the hospital system in 2 years. The document also noted the following, ?please arrange hospital follow up with any physician whom the patient currently sees Facility Physician at Cary House Adult Group Home or any PCP otherwise seen.? A handwritten note indicated, ?PCP changed when admitted to Cary?.
3. Further review of the resident?s nurse?s note documented resident #1 transported to a local hospital again on July 15, 2020. A review of the discharge document July 16, 2020, resident to ?follow up with physician in 5 days, renal failure need to repeat bmp in 5 days?. The document also noted, ?hospital follow up with PCP? July 23, 2020, @10:45, facility cancelled appointment?facility to arrange hospital follow up with visiting physician?, per staff #1.
4. Interview with collateral witness, the facility had not arranged for resident #1 to see a physician in over a year. According to interviewee, Staff #1 was strongly encouraged, on 7-21-20 to schedule an appointment for resident #1 to see a physician.
5. During the inspector?s interview with staff #1, the resident refused to see a doctor. However, a review of the resident?s nurses noted did not document resident?s refusal. When asked if resident had been scheduled to see a physician, Staff #1 stated the resident was recently seen by the physician that visits the facility. The date of the visit could not be determine, but it was following staff #1?s interaction with another agency?s investigator on 7-21-20.
6. Resident #1, during interview on 8-11-20, informed the inspector of not having seen a doctor since being at Cary Avenue, but recently saw the physician that visit the facility.
7. Staff #1 acknowledged resident #1 did not have the requested 5 day follow-ups noted in the two discharge documents.

Plan of Correction: Upon admission all residents will have a pcp assigned. Any ER or doctor recommendations will be addressed by the next business day Administrator and/or designee and documented.

Standard #: 22VAC40-73-650-F
Complaint related: No
Description: Based on document review and staff interview, the facility failed to ensure whenever a resident is admitted to a hospital for treatment of any condition, the facility shall ensure that the primary physician is aware of all medication orders and has documented any contact with the physician regarding the new orders.

Evidence:
1. During complaint inspection, a review of resident #1?s discharge document, June 23-June 26, 2020, noted resident?s medication change, start cephalexin (Keflex) and stop: Amlodipine (Norvasc), Aspirin and Enalapril- Hydochlorothiazide (Vaseretic)
2. A review of resident #1?s discharge document dated July 15-16, 2020, also noted resident?s medication change, stop: Aspirin, Vaseretic and Norvasc. A written prescription signed and dated by a prescriber on 7-16-20 for medications to be discontinued was also in the resident #1?s record.
3. A review of the resident?s June 2020 medication administration record (mar) documented resident continued to receive the aforementioned medications. A review of the July 2020 mar documented the Aspirin, Vaseretic and Norvasc were last administered July 14, 2020.
4. During interview with staff #1, resident was seen by the visiting physician. A review of resident?s physician?s orders noted the physician signed the resident physician?s order to discontinue medications on July 28 and July 30, 2020. Prior to the physician?s visit to the facility the resident did not have an assigned physician.
5. Staff #1 acknowledged resident #1, did not have a physician to review documents following hospital stays.

Plan of Correction: Upon admission all residents will have a pcp assigned. Any ER or doctor recommendations will be addressed by the next business day Administrator and/or designee and documented.

Disclaimer:
A compliance history is in no way a rating for a facility++.

The online compliance history includes only information after July 1, 2003. In addition, the online compliance history includes information regarding adverse actions that may be the subject of a pending appeal. An adverse action is not final until a provider has exhausted or waived all due process rights. For compliance history prior to July 1, 2003, or information regarding the status of pending adverse actions, please contact the Licensing Inspector listed in the facility's information. The Virginia Department of Social Services (VDSS) is not responsible for any errors in or omissions from the compliance history information.

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