VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Stratford House
1111 Main Street
Danville, VA 24541
(434) 799-2266

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: April 2, 2021 and April 6, 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 4/2/2021 and concluded on 4/6/2021. A self-reported incident was received by the department regarding allegations in the areas of resident care and related services. 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 inspection supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the monitoring inspection but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on documentation and interview, the facility failed to administer medication in accordance with the physician's or other prescriber's instructions. EVIDENCE: 1. A self-reported incident received on 3/30/2021 shows that the facility stated that an order for scheduled Lasix (furosemide) 40 mg was discontinued by accident. The PRN (as needed) Lasix 40 mg should have been the only Lasix prescription discontinued. This was confirmed in a telephone interview with staff 1 on 4/6/2021. 2. A physician's order dated 2/16/2021 shows that furosemide (Lasix) 40 mg once a day as needed for edema should be discontinued. 3. Both the scheduled furosemide 40 mg once a day and the furosemide 40 mg once a day as needed for edema show they were discontinued on the medication administration (MAR) as of 2/18/2021. 4. The MAR shows that administration of this scheduled medication did not resume until 3/29/2021.
Plan of Correction:	What has been done to correct? The order was corrected. How will recurrence be prevented? This medication error was accidentally committed by a Nurse Consultant contracted to assist in the absence of an RCD. Should any such instance occur in the future where any outside Nurse is assisting with processing orders, a Commonwealth Senior Living Nurse will provide oversight to ensure that the orders are processed correctly. Person Responsible: Director of Resident Care Services and Executive Director