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: Nov. 23, 2020 and Nov. 24, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS.

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. This monitoring inspection is in follow-up to a previously issued high-risk violation notice issued on October 14, 2020 as well as a monitoring inspection for the facility's Conditional license. The inspection was initiated on November 23, 2020 and concluded on November 24, 2020. The executive director was contacted by telephone to initiate the inspection. The executive director reported that the current census was 70. The inspector emailed the executive director a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, physician's orders, Medication Administration Records, and other facility documentation submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. 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 a review of resident records, 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: -Resident # 1 has a physician's order dated November 3, 2020 that states, "Acetaminophen 500MG Tab, 1 tablet by mouth 3 times a day for chronic pain daily at 09:00, 13:00, 18:00". However, the resident's electronic Medication Administration Record (E-MAR) for November 2020 indicates that the medication was not administered according to physician's orders at 1:00 p.m. on the following dates: November 3, 4, 9, 14, 15, and 23, 2020 as the documentation blocks were blank and there were no exception notes to indicate why the medication was not administered. The same physician's order also states, "Gabapentin 300MG Capsule, 1 capsule by mouth 2 times a day every morning and at lunch for chronic pain daily at 08:00 and 12:00." However, the resident's E-MAR indicates that the medication was not administered according to physician's orders at 12:00 p.m. on the following dates: November 3, 4, 9,14,15,18, and 23, 2020 as the documentation blocks were blank and there were no exception notes to indicate why the medication was not administered. -Resident # 2 has a physician's order dated November 3, 2020 that states, "Combigan 0.2%-0.5 % Eye Drops, instill 1 drop in each eye 2 times a day at 08:00 and 20:00." However, the resident's E-MAR indicates that administration times of 8:00 a.m., 5:00 p.m., 6:00 p.m., and 8:00 p.m. The E-MAR also indicates that the medication was not administered at 5:00 p.m. on the following dates/times: November 1-3, 2020, November 17-23, 2020, 6:00 p.m. on November 1-17, 2020 and 8:00 p.m. November 4-23, 2020. There are only exception notes documented for November 15-16, 2020 stating that the medication was "reordered/not available".
Plan of Correction:	It is the policy of Discovery Village to ensure that all residents receive their medications as ordered and scheduled per the medical providers orders. Resident #1 Resident will be given all scheduled meds as ordered by the medical provider. RMA?s and LPN?s will follow the 5 rights for med administration to include the correct dosing time daily. Resident #2 Resident?s order was changed several times during the month of November due to another medical issue. This resident was given her eye gtts as ordered by the Medical provider however the EMAR did not reflect the change hence leaving blank spaces on the EMAR. RMA?s and LPN?s will monitor all order changes to ensure that they are reflected on the EMAR correctly. All RMA?s will complete a 4 hour refresher course on Medication Ethics, Medication Documentation and also a refresher in Diabetic Management as a review. All RMA?s will check for missed meds at the end of each med pass, the DHW will check daily for 1 month then randomly weekly for missed meds as well to ensure that all medications are given as ordered and to prevent further medication errors.