VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Dogwood Crossing Senior Living And Memory Care
130 Deer Ridge Trail
Tazewell, VA 24651
(276) 385-7150

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: April 9, 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 04/09/2021 and concluded on 04/12/2021. A self-reported incident was received by the department regarding allegations in the areas of resident care. 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. 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 #:	22VAC40-73-270-2
Description:	Based on review of documentation submitted by the facility as part of a self-reported incident, the facility failed to ensure restraint training was provided for staff of the assisted living facility prior to being involved in the care of residents in restraints including the health needs of such residents. EVIDENCE: 1. According to documentation review and correspondence with the administrator on the evening of 04/02/2021 at 7:11 pm staff # 1 was observed on survillance footage applying a gait belt to resident # 1 while he was in his wheelchair to confine him to the chair to keep from falling. Resident # 1 was restrained from 7:11 pm on the evening of 04/02/2021 until 5:00 am on 04/03/2021. 2. Staff # 1 did not have training on restraining residents prior to applying the restraint to resident # 1.
Plan of Correction:	All staff at hire and yearly already received training on restraints. The facility administrator would have followed proper policy and procedure and reviewing of safety and use, if the restraint would have been medically necessary. Terminated employee chose to make that decision on her own and had no authority or right to make the decision to restrain a resident. [sic]
Standard #:	22VAC40-73-710-F
Description:	Based on documentation review of a self-reported incident, the facility failed to ensure all of the required conditions were met when restraints are used in emergencies. EVIDENCE: 1. Based on information submitted by the facility and email correspondence with the administrator, it was reported to the administrator of the facility on 04/09/2021 that on the evening of 04/02/2021 and into the morning of 04/03/2021 staff # 1 used a gait belt to restrain resident # 1 to his wheelchair to keep him from falling. 2. Resident # 1's physical examination report dated 08/25/2020 states he has a diagnosis of intermittent agitation, delirium and altered mental status and is at risk for falls. 3. The Uniform Assessment Instrument for resident # 1 dated 04/06/2021 states he has wandering/passive behaviors and is disoriented to some spheres, some of the time. 4. The Individualized service plan (ISP) for resident # 1 dated 09/18/2020 states he is at high risk for falls, has impaired mobility, and will be checked on every two hours by staff as he does not understand what his signaling device is used for due to serious cognitive impairment. 5. According to the report sent by the facility and email correspondence with the administrator on the evening of 04/02/2021 at 7:11 pm staff # 1 is seen applying a gait belt around resident # 1 while he was sitting in his wheelchair via surveillance footage. The surveillance footage showed that resident # 1 was restrained from 7:11 pm on 04/02/2021 until 5:00 am on 04/03/2021. During the time the resident was restrained to his wheelchair he was in the common area where staff were present and was assisted to the restroom several times by staff # 1. 6. According to correspondence with the administrator resident # 1 is unable to verbalize what the gait belt was used for and he was unable to take the belt off himself to get up from the wheelchair. 7. According to documentation review this facility does allow restraints to be used at any time. According to nursing notes dated 04/09/2021 staff # 1 stated on the evening of 04/02/2021 she restrained a resident with a gait belt to keep him from falling anymore. This was reported to the administrator on 04/09/2021. 8. According to documentation review and correspondence with the administrator an oral or written order from a physician was not obtained within an hour of administration of the emergency restraint, the resident was restrained longer than two hours and was not transferred to a medical or psychiatric inpatient facility or monitored in the facility by a mental health crisis team until his condition had stabilized to the point that the attending physician documents that restraints are not necessary, the resident's legal representative or designated contact person was not contacted within 12 hours of administration of the emergency restraint, the facility did not review the resident's ISP within one week of the application of the emergency restraint and document additional interventions to prevent the future use of emergency restraints.
Plan of Correction:	Employee took it upon herself not following any regulations or policy & procedure to restrain a resident was terminated. A complaint was filed by the facility administrator to the VA Board of Nursing on the terminated employee?s C.N.A. License and Medication Aide Registry. Facility administrator and staff would have followed the proper policy and procedures if the resident medically needed a restraint. The terminated employee chose to make that decision on her own and had no authority or right to make the decision to restrain a resident. Facility administrator will in-service all staff members on policy and procedures in regards to restraints to assure understanding that employees cannot restrain a resident in anyway without proper documentation, notifications, and orders. [sic]