VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Heritage Green Assisted Living Communities
201 & 202 Lillian Lane
Lynchburg, VA 24502
(434) 385-5102

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: March 2, 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 2/10/2021 and concluded on 3/3/2021. 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 emailed the Administrator 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.

Violations:

Standard #:	22VAC40-73-650-F
Description:	Based on a review of resident records and facility documentation, the facility failed to obtain new orders for all medications and treatments prior to or at the time of the resident's return to the facility. EVIDENCE: 1. The record for resident 1 has a notation dated 11/21/2020 that resident 1 was unresponsive and that EMS was called to transport the resident to the hospital. A hospital discharge summary dated 11/24/2020 indicates that resident 1 has a diagnosis of Syncope and a ZIO Patch was placed on resident 1 prior to his discharge from the hospital but specific indications/instructions for the ZIO were not addressed in the discharge summary. An email received by the LI from staff person 2 expressed that on 11/24/2020 staff person 1 called and talked to resident 1's nurse at the hospital as a follow up because there was not a specific date to remove the patch, and the nurse told staff person 1 that the patch is to be removed 12/7/2020. A notation made in resident 1's record on 11/24/2020 by staff person 1 indicates that the ZIO patch is to be removed on 12/7/2020 and sent to resident 1's cardiologist. A physician order was not obtained with instructions on the care and monitoring of the ZIO patch or when to remove or where to send the patch for reading. 2. The record for resident 1 has documentation from the local hospital emergency room dated 2/6/2021 that resident 1 was sent to the emergency room for moderate weakness and possible syncope like activity. Documentation present indicates that when resident 1 arrived at the emergency room, a LOP recorder was observed to be in place on the resident. A facility incident report dated 2/6/2021 has documentation that the ZIO patch was still on resident 1 when they were sent out to the hospital on 2/6/2021 for a syncope episode.
Plan of Correction:	What: On 11/24/2020 resident #1 returned from the hospital wearing a Zio patch. No instructions were provided so facility nursing staff contacted the resident #1?s Cardiologist to obtain instructions. Instructions were given at that time to remove the patch on 12/7/20 and send the patch to the cardiologist. At this time, the facility nurse did not transcribe these instructions onto the treatment record to remind staff to remove, as a result, the patch was not removed. Resident was sent to hospital by facility staff on 2/6/2021 and the Zio patch was still on resident. The Zio patch was replaced at the hospital and the resident returned to the facility with instructions to remove 2/13/2021. Zio patch was removed by facility nurse and returned as instructed on 2/13/2021. How: To reduce the risk of recurrence, the facility implemented the following changes: 1. When resident returned with Zio patch on 2/6/2021, a reminder to remove the patch was placed on resident # 1?s treatment record and removed and returned as instructed. 2. The staff member responsible for transcribing the instructions, received in-service training on proper protocol on documenting orders/ instructions on the resident treatment record and re-admission protocol to include full body skin check for any devices. Completed 3/3/2021. 3. The Resident Care Director or designee will be responsible for training care staff on how to manage any new medical devices that may be ordered. If staff are unfamiliar with their findings, they are to report immediately to the Resident Care Director or Executive Director. a. Care staff in-service training on reporting unfamiliar device or care needs will be completed by 3/19/2021. Ongoing: To maintain compliance, the Resident Care Director or designee will 1) Ensure all physician?s orders, including those for medical devices, have been obtained and the instructions on removal of devices has been added to the EMAR system. 2) RCD or designee will review the E-Mar Dashboard daily to ensure all orders obtained have been reviewed and approved. 3) RCD or designee will audit new admissions or re-admissions resident chart in accordance with facility policy. 4) Executive Director will monitor the Dashboard to ensure orders are being reviewed timely. 5) RCD will submit all findings at the quarterly QA meetings.