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

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 5/17/2021. A complaint was received by the department regarding allegations in the areas of administration of medications. The administrator was contacted by telephone and email 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 did not support the allegation of non-compliance with standards or law, and violations. Violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on a review of the medication administration record (MAR) for one resident, medications was not administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice out lined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: The March 2021 medication administration records for resident # 1 state: Bactrim (effective 3/24/21)- take tablet by mouth every 12 hours times ten days for infection. Medication was given for nine days vs, ten.
Plan of Correction:	All medications were given to resident according to the 5 rights of medication administration Medication was given nine days vs. ten. See attached MAR.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on a review of the March 2021 medication administration record (MAR) for one resident, the facility failed to document and account for medication administered to one resident. Evidence: The facility's medication management plan (revised 11/16/19) that was in effect at the time of the incident states "Two licensed nurse/registered medication aides will do the count of each controlled drug, one accounting for the actual number/amount of the drug, the other verifying the number/amount recorded as being available on the control sheet." A review of the March 2021 medication administration record for resident # 1 found no documentation to support the administration of Lorazepam on 3/24/21 at 8 am and 2 pm. The MAR was blank (no initials or signatures); however, a review of the Individual Resident's Controlled Substance Record for resident # 1 documented Lorazepam as being given on the date and time.
Plan of Correction:	Medication not documented on March MAR for 5 doses (5/24-5/25). Meds discontinued on 3/24 at 8:59 am by pharmacy. However, med not discontinued on MAR. Will constantly check MAR for activity to prevent error.