VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Discovery Village at the West End
2422 University Park Boulevard
Richmond, VA 23233
(804) 554-1555

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: Oct. 14, 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 October 14, 2020 and concluded on October 15, 2020. A self-reported incident was received by the department regarding allegations in the areas of medication administration. The executive director was contacted by telephone to conduct the investigation. The licensing inspector requested 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 a violation was issued. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return it to the licensing office within 10 calendar days. Please specify how the violation will be corrected. The plan must contain: 1) step(s) 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 during this inspection. I can be reached at Kimberly.M.Davis@dss.virginia.gov or (804) 662-7578.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on an incident report from the facility's Executive Director, the facility failed to ensure that 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: Per the facility's incident report, Resident #1 who is a diabetic, has a physician's order dated 10-6-2020 that states, "Inject 3 units before meals. Hold for blood glucose less than or equal to 80 or if not eating. Notify provider of blood glucose less than 80 or greater than 400." Staff #1 documented on the October 2020 MAR that she took the resident's blood sugar at approximately 12:00 p.m. on 10-9-2020 and it was 57 and that three units of insulin were administered to the resident at lunchtime. Resident did not appear to eat lunch as lunch was still in a container from the kitchen. Nurses Notes on 10-9-2020 at approximately 3:00 p.m. by Staff # 2 stated, "Called to resident room by staff. Resident observed lying on living room floor, with arms clenched up and mouth clenched, eyes closed and diaphoretic. Blood sugar taken and was 'Low'. Attempted to arouse resident and get her to eat icing and drink Coke, however unable to. Call placed to 911. EMS arrived at community. IV started and resident treated with 10% Dextrose by EMS. Resident started coming to and transferred to stretcher. Resident taken to Henrico Doctors Hospital. NP made aware."
Plan of Correction:	All staff who are responsible for checking blood sugars and insulin will be re-educated on proper administration and The 5 Rights of medication administration. LPN will perform daily checks of blood sugar readings and weekly audits of blood sugar orders. Documentation of these checks will be available to providers and DSS upon request.