VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Cedar Bluff
500 Clinic Drive
Cedar bluff, VA 24609
(276) 596-9750

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: April 14, 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 04/14/2021 and concluded on 04/14/2021. A self-reported incident was received by the department regarding allegations in the areas of medication administration. 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

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on information provided as a result of a self-reported occurrence and review of physician?s orders, medication administration records (MAR) and staff statements, the facility failed to ensure that medications were 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: 1. Resident #1 was admitted to the facility on 11/11/2019. 2. On 3/23/2021 a physician prescribed 25mg Seroquel gel to be administered topically every morning for mood and 50mg Seroquel gel to be administered topically every evening for agitation. 3. The facility conducted a Medication Cart review and discovered there was an excess amount of Seroquel gel. There were 10 extra doses of the 25mg Seroquel gel prescribed to be administered topically every morning and 12 extra doses of the 50mg Seroquel gel prescribed to be administered topically every evening. 4. The Staff Initials on the MAR indicated the 25mg Seroquel gel had been administered on March 24 th -31 st 2021, and April 1 st -5 th 2021; the MAR also indicated that the 50mg Seroquel gel had been administered on March 23, 24, 26 th -31 st , and April 1 st -4 th 2021. On 04/05/2021 a physician?s order discontinued the Seroquel gel 25mg and Seroquel gel 50mg. 5. Interviews with Staff #1-6 indicate they were unsure if they had administered the Seroquel gel. One staff stated she was sure she had administered the Seroquel gel at some point, but could not recall specific dates or times.
Plan of Correction:	In-service RMA staff on 5 rights of medication administration by RCD or designee. In-service RMA staff on medication management and administration of all medications including gels. In-service conducted by RCD or designee. Random Cart to MAR audits will be conducted by RCD or designee to ensure medications are being given per prescribers orders. All RMS staff involved in not administering the gel were issued written warnings. Warnings were issued by RCD/ED. [sic]