VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Virginia Beach
937 Diamond Springs Road
Virginia beach, VA 23455
(757) 493-9535

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: March 11, 2021 , March 12, 2021 , March 13, 2021 and March 16, 2021

Complaint Related: Yes

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 complaint inspection was initiated on March 5, 2021 and concluded on March 16, 2021. A complaint was received by the department regarding allegations in the areas of medication administration, and resident care. The Executive Director was contacted by telephone to conduct the investigation. The licensing inspector emailed the Executive Director a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. The complaint is valid.

Violations:

Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to ensure Individualized Service Plans (ISPs) were reviewed as needed as the condition of the resident changed. Evidence: 1. Resident #1?s Progress Notes from 09-05-2020 to 02-26-2021 documented 13 incidents of combative behaviors, including grabbing staff by the throat and resistance to care. 2. Resident #1?s current ISP dated 02-28-2021 did not address resident?s combative behaviors. 3. Staff #1 and staff #2 confirmed Resident #1?s ISP did not address the behaviors mentioned.
Plan of Correction:	The Health & Wellness Director or Designee has collaborated with resident #1?s Primary Medical Provider and Psychiatric Provider for medication management related to behaviors. The Health & Wellness Director or Designee will reassess and update resident #1?s Individualized Service Plan to reflect behaviors as sited no later than 4/9/2021. The Regional Dementia Care Specialist, Executive Director, Health & Wellness Director or Designee will provide education to all staff regarding Clare Bridge approach and behavioral expressions no later than 6/2/21. To assist with ongoing compliance, The Health & Wellness Director or Designee will conduct Individualized Service Plan chart audits monthly on resident #1 for three (3) months.
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to ensure medications were administered in accordance with the prescriber's instructions. Evidence: 1. An incident report received by email on 02-13-2021 documented regarding Resident #1, ?While performing routine chart audits, a transcription error was discovered. Error was corrected upon clarification of order. Medication was given 11 days prior to order clarification. Order stated Remeron 30mg QHS [bedtime] but was entered as BID [twice daily] in PCC. [Nurse Practicitioner] aware of transcription error and wrote clarification order...?. 2. Resident #1?s Medication Administration Record [MAR] documented resident received Remeron 30mg BID from 01-22-2021 until 02-04-2021. The order was clarified by Nurse Practitioner in Progress Notes dated 02-04-2021, ?It is also noted Remeron was given in error 30mg bid, corrected to @ hs?? 3. Staff #1 and staff #2 confirmed in interview that the aforementioned medication was administered incorrectly for 13 days.
Plan of Correction:	The Health & Wellness Director or Designee has reviewed and conducted an audit on resident #1?s current medication list. Updated medication orders at time of audit. The Health & Wellness Director or Designee will provide education on Transcription of medication orders to current Registered Medication Aide and License Practical Nurses no later than 6/2/2021. To assist with ongoing compliance, the Health & Wellness Director or designee conduct a medication audit on resident #1?s chart monthly for three (3) months.