VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Marian Manor
5345 Marian Lane
Virginia beach, VA 23462
(757) 456-5018

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: March 11, 2021 , March 12, 2021 , March 16, 2021 , March 17, 2021 and March 18, 2021

Complaint Related: No

Areas Reviewed:

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

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 3/11/21 and concluded on 3/18/21. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 101. The inspector emailed the Administrator the list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, and staff schedules 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.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review and discussion, the facility failed to ensure the physical examination report documented the description of the person?s reaction to known allergies. Evidence: 1. Resident #3?s physical examination report dated 1/20/21 did not document a description of reaction to known allergy: Ampicillin. 2. Staff #5 acknowledged Resident #3?s physical examination report dated 1/20/21 did not include the aforementioned information.
Plan of Correction:	The Medical Record was updated with this information for the resident after consulting with her family and her attending physician. Chart audit was conducted on all residents to check for reactions to known allergies and document reactions if they were not in the record. Charge Nurses and Medication Aides were in-serviced on the importance of having a reaction for any allergy documented in the medical record and on the MAR. The History and Physical will be reviewed closely prior to admission to determine that this information is documented. If allergies occur after admission, the medical record will include the reactions. Medication Aides and Charges Nurses were in-serviced to make sure that the reaction is included in the documentation. The Director of Admissions will follow up to obtain the missing reactions. The Director of Nursing and Executive Director will double check for completion on review.