VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Memory Care at Chesapeake
130 Great Bridge Boulevard
Chesapeake, VA 23320
(757) 436-2109

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Nov. 10, 2020 , Nov. 13, 2020 , Nov. 16, 2020 and Nov. 17, 2020

Complaint Related: Yes

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 November 10, 2020 and concluded on November 17. 2020. The complaint was alleging resident?s blood levels were not monitored and therapy orders were not followed. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Executive Director a list of documentation required to complete the investigation. Records reviewed and interviews conducted. Consultation was provided regarding physical examination requirements, medication administration record (MAR) documentation, and individualized service plan (ISP) services. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint(s) but identified during the course of the investigation can be found on the violation notice. The complaint is valid.

Violations:

Standard #:	22VAC40-73-470-A
Complaint related:	Yes
Description:	Based on record review and discussion, the facility failed to ensure that either directly or indirectly, that the health care services needs of residents are met and included the facility assisting residents in making appropriate arrangements for health care services. Evidence: 1. Resident #1?s date of admission was 09/22/20. The resident was a direct admit from a local hospital. Hospital ?Discharge Summary Notes? documented, ??patient will be followed by Coumadin clinic as outpatient with INR goal of 2-3? written by [Hospital Physician #1]. 2. Resident #1?s record did not contain documentation that indicated the resident was followed by a Coumadin clinic as an outpatient as of the date of this inspection. Nor did the resident?s record have documentation of the Coumadin clinic being contacted to follow the resident as written by the physician. 3. Staff #1 stated Resident #1 was being followed by hospice, and therefore no follow up with the Coumadin clinic was warranted. 4. Resident #1 was admitted to the hospital on 10/12/20. ?H&P [History & Physical] Summary Notes? by [Hospital Physician #2] documented, ??is being admitted with right chest wall hematoma? Coumadin was started ? It is not clear whether patient had any INR checked?? The hospital Admitting Diagnosis, Assessment, Current Problems and Procedures documented, ?1. Acute kidney injury 2. Ref right pectoral hematoma likely traumatic 3. Possible over anticoagulation?? 5. Staff #1 confirmed that arrangements were not made for Resident #1 to be followed by a Coumadin clinic.
Plan of Correction:	Resident Care Director and/or designee will review all discharge summaries during admission and upon return to community. Resident Care Director and/or designee will alert all outside agencies of any changes in care noted during view. PT INR was drawn on 9/29/20 by American Health Lab.
Standard #:	22VAC40-73-480-C
Complaint related:	Yes
Description:	Based on record review and discussion, the facility failed to arrange for specialized rehabilitative services by qualified personnel as needed by the resident including physical therapy and occupational therapy. Evidence: 1. Resident #1?s ?Resident Physical Examination Report? dated 09/18/20 documented, ?Therapy Orders: as per PT/OT [Physical Therapy/Occupational Therapy]?. 2. Resident #1 record had no documentation indicating the resident received PT or OT from the date of admission on 09/22/20 by the date of the resident?s readmission to a local hospital on 10/12/20. Nor was there documentation of PT/OT being made aware of the physician?s order or request for clarification from the physician. 3. Staff #1 stated Resident #1 did not receive PT or OT services as ordered by the physician.
Plan of Correction:	Resident #1 was admitted from hospital after history and physical was sent to community. After careful review, the physician decided that hospice services were more appropriate. Resident was started on hospice services on 9/24/2020. Resident Care Director and/or designee will ensure to review and clarify all history and physicals prior to admission of potential residents to community.