VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Pearl at Watkins Centre
650 Watkins Centre Parkway
Midlothian, VA 23112
(804) 893-0067

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: Jan. 22, 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 self report was received by the Department regarding a medication error. A complaint was later received afterwards in regards to the medication error. An investigation was initiated on 1/22/2021. The licensing inspector reviewed medication administration records and physician orders. Evidence gathered during the investigation supported the report of the medication error and non-compliance with applicable standards or laws, and violations are documented on the violation notice issued to the facility

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on a review of medication administration records (MARs) and physician orders for resident # 1, medications were not administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Resident # 1 has a physician order for December 2020 and January 2021 to take Valsartan/HCTZ 320-12.5 mg tab "take one tablet by mouth every day for hypertension". It was self reported by the facility and documented on the MARs for December 2020 and January 2021 for resident # 1 that Valsartan/HCTZ was not administered per the physician orders from 12/23/2020 to 1/20/2020.
Plan of Correction:	1. In-service will be conducted with all RMA (Registered Medication Aide) on the following: Protocol for the acceptance of medications from pharmacy. Protocol for notification of missing medications 2. Weekly review of medication Exceptions Report will be conducted by ED (Executive Director) beginning 3/26/2021. To be completed by WD (Wellness Director) once hired. 3. Monthly review of POS(Physician Orders) for accuracy. CSS/WD on 4/13/2021. MD on 4/21/2021. 4. Quarterly audits will be performed by pharmacy. Southern Pharmacy completed audit on 2/2/21. 5. Monthly audits of Med Exception reports, signed POs, clinical in-services . SR Ed on 4/13/2021.
Standard #:	22VAC40-73-680-I
Description:	Based on a review of medication administration record (MAR) for one resident, facility staff failed to document the reason for a medication omission. Evidence: A review of the December 2020 and January 2021 medication administration records (MARs) for resident # 1 found that a medication (Valsartan/HCTZ) was not administered from 12/23/20 to 1/20/2021. The MARs did not document a reason for the medication not being administered.
Plan of Correction:	In-service will be conducted with all RMA on the following: Proper documentation of missing medications/med exceptions in EMAR (Electronic Medication Administration Record). Protocol for notification of missing medications Weekly review of Medication Exceptions report will be conducted by the ED (Executive Director). ED beginning 3/26/2021, to be completed by WD (Wellness Director) once hired.