VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Essex House
17976 Tidewater Trail
Tappahannock, VA 22560
(804) 443-5921

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: April 22, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

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 4/22/2021 and concluded on 5/19/2021. A complaint was received by the department regarding allegations in the areas of medication administration, personnel and resident care and accommodations . The administrator was contacted by telephone and email to conduct the investigation. The licensing inspector emailed the administrator information required to complete the investigation. The evidence gathered during the investigation supported one of the allegations of non-compliance with standards or law and violations were issued. Violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-530-C
Complaint related:	No
Description:	Based on a review of the individualized service plan for one resident and the 24 hour communication log, the facility failed to provide freedom of movement for the resident to personal spaces. The facility is locking resident out of the ensuite bathroom. Evidence: 1. A goal was added to the individualized service plan for resident # 1 on 3/26/2021 "lock installed on BR door. Staff to lock door." 2. For resident # 1 - The 24 Hour Shift Communication form instructs staff working 3pm-11pm "check BS, dump trash, lock BR door".
Plan of Correction:	Resident had access to bathroom with staff upon request at nights. Daughter requested a lock be installed on BR (bedroom) door. BSC was provided sanitary wipes. Will consult with licensing if family request in the future. Lock was removed.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on a review of February 2021 and March 2021 medication administration record (MAR) for one resident, medication was not 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 is prescribed a lidocaine patch with instructions "apply1 patch to affected area every morning for pain, remove at bedtime, 12 hours on, 12 hours off". An allegation was received that the lidocaine patch is sometimes not applied as ordered by the physician. Staff # 1 wrote in an email to the licensing inspector "_____(resident) is known to remove patch at times because it is irritating to her and this isn?t discovered until nights when RMA?s go to remove it. There has been some days where it has been later than an hour after scheduled time because of emergencies/incidences beyond our control". 2. The April 2021 MAR for resident # 1 states "Humalog Kwik 100U/ml, check BP before meals and inject subcutaneously per SSI(sliding scale insulin): 150-199 2U, 200-249-4U, 250-299-6U...". On 4/19/21 at 5pm, 4/21/21 at 8am, 4/26/21 at 8am and 12 pm and 4/27 at 8am and 12pm, staff # 2 documented under notes "BP >150" with no additional doses documented. The symbol > denotes more than.
Plan of Correction:	BS > 150 should be <150 , insulin held. The AccuFlo system is set when medication is held- it is charted as "Do not chart". It doesn't record your initial but it does make a notation in notes why it was held and RMAs initials. Training was given to RMA.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on the review of the April 2021 medication administration record (MAR) for one resident, the Mar did not contain the initials of staff administering medication. Evidence: 1. The MAR for resident # 1 had a BP reading with no staff initials for humalog kwikpen before meals on 4/19/21 at 5pm, 4/1/21 at 8am, 4/26/21 at 8am and 12 noon and 4/27/21.
Plan of Correction:	RMAs are writing date and initials on patch before applying. Staff has witnessed resident is removing the patch. Will encourage resident to keep patch on. Training provided to RMA.