VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Shenandoah Place, Inc.
50 Burkholder Lane
New market, VA 22844
(540) 740-4300

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: April 26, 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 04/26/21 and concluded on 05/12/21. A complaint was received by the department regarding allegations in the area of medication administration. The administrator was contacted 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 allegation 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. Upon receipt of the violation notice, a plan of correction is requested for each violation. The plan of correction should include 1) Steps to correct noncompliance of the regulation; 2) Measure(s) to prevent re-occurrence of noncompliance; 3) Person(s) responsible for implementing each step and/or monitoring any preventative measure(s) and 4) The date by which the noncompliance will be corrected.

Violations:

Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based upon review of residents' Medication Administration Records (MARs), the facility failed to implement procedures in the medication management plan to ensure documentation of effectiveness of "as needed" PRN medications. FINDINGS: 1) The facility medication management plan indicates a daily review of the medication administration records by the director of nursing, administrator or the medication supervisor shall be performed to ensure accurate and complete documentation to include timely documentation of PRN medication. 2) Resident A has the following order: Acetaminophen 325mg-Take 2 tablets by mouth every 4 hours as needed for mild pain or fever greater than 99 degrees Fahrenheit. Do not exceed 3gm Acetaminophen in 24 hours from all sources. Notify MD if no relief in 24 hours. a. Documentation in the MAR indicates medication was administered on 04/06/21 at 11:39pm for left ankle pain. b. Results following the administration of medication were documented at 5:33am on 04/07/21 and indicate "resident said it helped." c. Documentation in the MAR indicates medication was administered on 04/10/21 at 2:39am for headache. d. Results following the administration of medication were documented at 6:12am and indicate "resting in bed with eyes closed." 3) Resident G has the following order: Ibuprofen 200mg-Take 2 tablets by mouth every 4 hours as needed for pain or fever. Call hospice if symptoms persist greater than 24 hours. a. Documentation in the MAR indicates medication was administered on 04/11/21 at 1:38am. b. Results following the administration of medication were documented at 4:00am and indicate "resident in bed with eyes closed."
Plan of Correction:	Medication management plan updated to define "timely" as it is open to interpretation; updated on 05/17/21. In-service scheduled to review updated plan with staff for 05/26/21.
Standard #:	22VAC40-73-670-1
Complaint related:	Yes
Description:	Based upon review of staff records and resident records, the facility failed to ensure staff administering medications are licensed by the Commonwealth of Virginia or is registered with the Virginia Board of Nursing as a medication aide. FINDINGS: Based upon review of the Medication Administration Records (MARs), documentation indicates staff A administered medications to residents A, B, C, D, E, F, G, H, I, J, and K on 04/09/21. a. Documentation submitted by the facility indicates staff A received an Associate of Applied Science Degree in Nursing on 05/08/2017. b. Staff A has not successfully taken the National Council Licensure Examination to obtain licensure as a registered nurse. c. Communication received from the administrator via email on 02/22/21 included a copy of an application for staff A to take the registered medication aide competency exam dated 02/22/21. The administrator indicated in the email received on 02/22/21 that staff A had been pulled from the medication cart. d. An email was received from the administrator on 04/14/21 containing a letter from the Commonwealth of Virginia dated 04/13/21 indicating staff A is authorized to practice as a provisional medication aide effective 04/13/21. e. Documentation in the Medication Administration Records (MARs), indicates staff A administered medications to residents A, B, C, D, E, F, G, H, I, J, and K on 04/09/21, which was prior to the authorization letter of 04/13/21.
Plan of Correction:	All staff scheduled to pass medications will have an approval letter to do so.