VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Carriage Hill Retirement
1203 Roundtree Drive
Bedford, VA 24523
(540) 586-5982

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: March 15, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 22VAC40-80 COMPLAINT INVESTIGATION.

Technical Assistance:

To ensure that the facility had a thorough understanding of standards, the licensing inspection and the administrator had a discussion regarding standards 650 A and 650 F.

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 virtual complaint inspection was initiated on 03/15/2021 and concluded on 04/12/2021. A complaint was received by the department regarding allegations in the areas of personnel, resident care and related services, buildings and grounds and emergency preparedness. 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 four 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. Based on a requested review of violations by the facility, this violation notice has been amended due to a review by the department that occurred on 01/06/2022.

Violations:

Standard #:	22VAC40-73-200-B
Complaint related:	Yes
Description:	Based on resident record review and staff interview, the facility failed to ensure that direct care staff who are responsible for caring for residents with special health care needs only provided services within the scope of their practice and training. EVIDENCE: 1. The record for resident 1 contained a physician?s order, dated 02/19/2021, that stated ?Fleets enema rectally once may use one more time if no results in one hour? and ?Indication - DX constipation?. The February 2021 medication administration record (MAR) for resident 1 contained documentation that the following registered medication aides (RMAs) administered the enemas on the following dates at 5:00 PM: staff 1 on 02/21/2021; staff 2 on 02/22/2021 and 02/24/2021; and staff 3 on 02/23/2021 and 02/26/2021. The March 2021 MAR for resident 1 contained documentation that the following registered medication aides (RMAs) administered the medication enemas on the following dates at 5:00 PM: staff 1 on 03/07/2021; staff 2 on 03/01/2021; and staff 3 on 03/05/2021, 03/08/2021, and 03/13-14/2021. The ?Commonwealth of Virginia Board of Nursing Medication Aide Curriculum For Registered Medication Aides? states on page 136 ?NOTE: The administration of enemas requires additional knowledge, skills, and clinical practice that are not addressed in this curriculum.? The records for staff 1, 2 and 3 did not contain documentation that these staff had additional knowledge, skills, and clinical practice or additional training related to administering enemas and staff 4 confirmed that staff 1, 2 and 3 did not have this additional training.
Plan of Correction:	Director of Nursing, Administrator, and/or designee will ensure direct care staff provide services within their scope of practice.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure that individualized service plans (ISPs) were reviewed and updated as the condition of a resident changes. EVIDENCE: 1. The January 2021 medication administration record (MAR) for resident 2 showed that starting on 01/16/2021 the resident started refusing multiple medications daily during the month of January 2021. The February 2021 MAR for resident 2 showed that during the month of February 2021 resident 2 refused multiple medications daily during the month of February 2021. The March 2021 MAR for resident 2 showed the resident refused all medications daily from 03/01/2021 through 03/14/2021 and refused all morning medications on 03/15/2021. 2. The ISP for resident 2, dated 01/04/2021, was not updated to reflect this significant change in resident 2?s condition.
Plan of Correction:	Director of Nursing and/or Administrator will review and update ISPs to reflect significant changes.
Standard #:	22VAC40-73-460-H
Complaint related:	Yes
Description:	Based on resident record review, the facility failed to ensure that all residents received personal assistance and care with bathing at least twice a week, but more often if needed or desired. EVIDENCE: 1. The Individualized Service Plan (ISP) for resident 1, dated 04/22/2020, showed the following: ?BATHING: Mechanical/Physical Assistance Staff will provide complete assistance with bathing and getting in/out of shower safely while encouraging resident to participate as able while using the following DME equipment: shower bench/seat, grab bars?; ?Person who will provide services: Direct Care Staff, Resident? and ?When & where services will be provided: Minimum of twice weekly & as needed in bathroom at Carriage Hill?. The record for resident 1 did not contain documentation that the resident had received any showers during the weeks of 01/24/2021 through 01/30/2021, 01/31/2021 through 02/06/2021, 02/14/2021 through 02/20/2021, 02/21/2021 through 02/27/2021, 02/28/2021 through 03/06/2021 and 03/07/2021 through 03/13/2021. 2. The ISP for resident 2, dated 01/04/2021, showed the following: ?BATHING: Supervision Staff will supervise resident while bathing and cue resident as needed. Staff will ensure resident is able to get in/out of shower safely with a gently [sic] hand.?; ?Person who will provide services: Direct Care Staff, Resident? and ?When & where services will be provided: Minimum of twice weekly & as needed in bathroom at Carriage Hill? The record for resident 2 did not contain documentation that the resident had received any showers during the time period of 01/24/2021 through 03/13/2021. 3. The ISP for resident 3, dated 10/08/2020, showed the following: ?BATHING: Mechanical/Physical Assistance Staff will provide complete assistance with bathing and getting in/out of shower safely while encouraging resident to participate as able while using the following DME equipment: shower bench/seat, grab bars?; ?Person who will provide services: Direct Care Staff, Resident? and ?When & where services will be provided: Minimum of twice weekly & as needed in bathroom at Carriage Hill?. The record for resident 3 did not contain documentation that the resident had received any showers during the weeks of 01/24/2021 through 01/30/2021 and 01/31/2021 through 02/06/2021. The record for resident 3 contained documentation that the resident had only received three showers from 02/07/2021 through 02/27/2021 and that the resident had only received one shower from 02/28/2021 through 03/13/2021.
Plan of Correction:	Director Nursing, Administrator, and/or designee will ensure proper documentation of showers to include refusals.
Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure that the medication aide or the person licensed to administer drugs routinely communicated issues or observations related to medication administration to the prescribing physician or other prescriber. EVIDENCE: 1. Document ?Medication Management Plan? states on page 8 the following: ?13. All staff is responsible for communicating daily, per shift, to the SIC (supervisor in charge), Administrator/DON any change in condition, problems, concerns, falls or other issues of a Resident that could have a negative effect on their medical status. The SIC is responsible for communication problems, concerns or changes in condition with the assigned physician either fax or phone.? 2. The March 2021 medication administration record (MAR) for resident 2 showed the resident refused all medications daily from 03/01/2021 through 03/14/2021 and refused all morning medications on 03/15/2021. 3. The facility failed to communicate the resident 2?s refusals of prescribed medications as evidenced by ?Progress Note? by Collateral 1, dated 03/15/2021, which showed on page 1 of 2 that ?Nursing relates that he (resident 2) has been much more cooperative. He is eating better. He is taking his medications.?
Plan of Correction:	The providers response for the "plan of correction" was not received as of 04/23/2021 and will not appear on this Violation Notice
Standard #:	22VAC40-73-650-B
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure that physicians or other prescriber orders for administration of all prescription and over-the-counter medications and dietary supplements included the diagnosis, conditions or specific indications for administering each drug and how often the medication is to be given. EVIDENCE: 1. The record for resident 1 contained a physician?s order, dated 02/25/2021, for ?Rx: Keflex 500 mg oral capsule SIG: 1 cap oral every 12 hr for 7 days?. The order did not contain the diagnosis or conditions or specific indications for administering the drug. 2. The record for resident 2 contained a physician?s order, dated 01/14/2021, for ?Rx: silver sulfadiazine (SILVADENE, SSD) 1 % cream Sig: Apply by topical route to the affected area (s).? The order did not contain the diagnosis, conditions or specific indications for administering the drug and how often the medication is to be given.
Plan of Correction:	Director of Nursing and/or Administrator will educate Physician to include diagnosis, condition, and specific indications for administration on orders.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on resident record review and staff record review, the facility failed to ensure that medications were administered in accordance with physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 2 contained a physician?s order, dated 01/22/2021, for ?NOVOLOG 100 UNIT/ML SOLN ? CHECK FSBS FOUR TIMES A DAY AND INJECT SSI AS FOLLOWS 150-199 = 1U, 200-249 = 2U, 250 ? 299 = 3U, 300-349 = 4U, >350 = 5U FOR DIABETES ? 8AM, 12PM, 4PM, 8PM Indicated for DIABETES?. The January 2021 Medication Administration Record (MAR) for resident 2 showed that on 01/09/2021 at 8AM the resident?s glucose reading was 305 and 5 units of Novolog were administered; however, according to the physician?s orders 4 units should have been administered. On this same date, at 8PM the resident?s glucose reading was 189 and Novolog was not administered to the resident; however, 1 unit should have been administered. On 01/10/2021 at 12PM the resident?s glucose reading was 222 and 3 units of Novolog were administered; however, 2 units should have been administered. On 01/14/2021 at 12PM the resident?s glucose reading was 274 and 4 units of Novolog were administered; however, 3 units should have been administered. The January 2021 MAR showed that on 01/01/2021 at 12PM, the resident?s glucose reading was 233; on 01/02/2021 at 12PM, the resident?s glucose reading was 247, at 4PM was 248 and at 8PM was 178; on 01/03/2021 at 12PM, the resident?s glucose reading was 164, and at 8PM was 218. The MAR does not contain documentation of how many units of Novolog were administered to resident 2 for these dates and times. The February 2021 MAR for resident 2 showed that on 02/20/2021 at 8AM the resident?s glucose reading was 220 and 4 units of Novolog were administered; however, 2 units of Novolog should have been administered.
Plan of Correction:	Director of Nursing and /or Administrator will educate Medication Aids on the dosing scale for insulin.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure that all residents? medication administration records (MARs) included the initials of the direct care staff administering medications. EVIDENCE: 1. The February and March 2021 MARs for resident 1 showed ?Enema (Fleet Enema) Insert and empty contents of 1 enema into rectum once for constipation for: constipation?. The MARs contained ?Medication Notes? by registered medication aide; staff 3, on 02/19/2021 and 03/03/2021 at 5:00 PM that ?Nurse Give?. 2. The MARs do not contain the initials of the direct care staff that administered the enema.
Plan of Correction:	Director of Nursing and/or Administrator will educate Medication Aids on proper documentation on MAR.