VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Harmony Collection @ Hanover Assisted Living and Memory Care
8227 Meadowbridge Road
Mechanicsville, VA 23116
(804) 212-2110

Current Inspector: Tamara Watkins (804) 662-7422

Inspection Date: Sept. 25, 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 9/25/20 and concluded on 11/18/20. A self-reported incident 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 received documentation from the administrator 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. Your plan(s) of correction must contain: 1) steps to correct the non-compliance with the standard, 2) measures to prevent the noncompliance from occurring again and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Return to the Inspector within 10 days.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on a written and verbal incident report submitted by facility staff dated 9/20/20 medication was not administered to a resident in accordance with the physician's order. Evidence: Resident #1 was observed on the floor in his bathroom by a CNA (staff #1) who responded to his call bell. His speech was slurred and the resident was unable to tell staff how he got on the floor. The LPN Supervisor (staff #2) was called to assess the resident, vitals were taken and the blood sugar was 27. Glucose 15 gel was given. 911 was called and the resident's blood sugar was taken again before leaving for the Memorial Regional Medical Center ER, it was 113. The resident was able to speak and laugh with staff. The facility staff investigated the incident and checked the resident's blood sugar monitor on 9/20/20 8am and it had a blood sugar level of 50. The RMA administered 4 units when it should have been held, the physician order states to give 4 units for a blood sugar reading of 80-149.
Plan of Correction:	The HealthCare Director educated staff #1 on the five right's of medication administration and demonstration of competency of blood sugar monitoring on 9-22-20. All medication administration staff were educated on 9/23 on Hypoglycemia. The Healthcare Director audited all residents with diabetes to verify hold perimeters are listed on the medication administration record. 12/4/2020