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: Jan. 26, 2021 and Jan. 28, 2021

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. This monitoring inspection is in follow-up to a previously issued high-risk violation notice issued on November 24, 2020 and was initiated on January 26, 2021 and concluded on January 28, 2021. The executive director was contacted by telephone to initiate the inspection. The executive director reported that the current census was 72. The inspector emailed the executive director a list of items required to complete the inspection. The inspector reviewed 4 resident records, physician's orders and Medication Administration Records (MARs) 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 oulined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. Commonwealth of Virginia Board of Nursing Medication Aide Curriculum for Registered Medication Aides, Revised May 21, 2013 states: a. Chapter 5, Section 5.1 titled, ? 5.1 ?Describe Three Types of Forms Commonly Used to Document Medication Administration ? states, ?Documentation is an important part of medication management. It is frequently referred to as the ?6th Right? of medication administration. b. Section 5.3 titled ?Document Medication Administration on the Medication Administration Record states, ?All medications administered or omitted? under ?What to Document.? 2. No documentation of medication administration or omission was completed on the January 2021 Medication Administration Record for the following: a. Resident # 1 has a physician's order for January 2021 that states, "Levothyroxine 200 MCG, 1 tablet by mouth every day for hypothyroidism at 6:00 a.m." and the order also states, "Levothyroxine 25 MCG, 1 tablet by mouth every day with 200 MCG tablet at 6:00 a.m". b. Resident #1's electronic Medication Administration Record (E-MAR) for January 2021 contained no documentation that both of the medications were administered according to physician's orders at 6:00 a.m. on the following dates: January 5 and January 9, 2021, as the documentation blocks were blank and there were no exception notes to indicate why the medications were not administered. 3. There is no documentation to support whether these residents received or did not receive their medications.
Plan of Correction:	LPN/RMA will perform daily med audit and missed med audit before leaving at the end of shift. LPN/RMA will add this to the end of shift reporting, ensuring that all meds are administered by documenting that variance report has been checked and all meds have been documented. Director of Health and Wellness will check 3 times weekly to follow up on documentation.