VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Carriage Hill Retirement
1203 Roundtree Drive
Bedford, VA 24523
(540) 586-5982

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Jan. 19, 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. A monitoring inspection was initiated on 01/19/2021 and concluded on 02/02/2021. A self-reported incident was received by the department regarding allegations in the areas of resident care and related services regarding medication administration. The acting administrator/assisted living facility administrator-in-training was contacted by telephone to conduct the investigation. The licensing inspector emailed the acting administrator/assisted living facility administrator-in-training 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 violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-680-B
Description:	Based on resident record review, document review and staff interview, the facility failed to ensure that medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. EVIDENCE: 1. The facility submitted a written report regarding an incident that occurred on 01/17/2021. The report revealed that staff 1 observed a medication sitting on resident 1?s shirt and assisted resident 1 in taking the medication.
Plan of Correction:	Plan of correction: 1.Our Administrator self-reported this incident, including the medication error to the state. The resident was sent out to the hospital for further evaluation. 2.Staff member involved in the incident was counseled appropriately for behavior. Appropriate action was taken in reporting this incident and the staff involved, to the appropriate regulatory agencies. An in-service was conducted with all staff regarding appropriate medication management practices, including but not limited to observation of the med pass, and appropriate action and documentation associated with a med pass. Mandatory additional training through our company training program was also initiated for all medication technicians to complete. 3.Our Director of Nursing is providing on the job training and is observing med passes at random with staff to ensure ongoing compliance. She is also spot-checking documentation in the EMAR system to ensure we are documenting med passes appropriately. 4.Weekly our Administrator and DON will meet to discuss nursing functions and med passes will be discussed to ensure we are operating within compliance ongoing.