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 14, 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. An inspection was initiated on 4/14/2021 and concluded on 5/19/2021 to follow-up on a self reported medication error. The administrator was contacted by telephone and email to conduct the investigation. The licensing inspector emailed the administrator for documentation required to complete the investigation. The evidence gathered during the investigation supported non-compliance with standards or law, and violations were issued. Violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on a review of the facility's written plan for medication management during the follow up of a self reported incident, facility staff failed to comply with the plan in disposal of medications. Evidence: 1. 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". The Medication Destruction form submitted to the Department for review did not have a number count, *1/2 bottle" was documented under number destroyed for Haldol on 3/3/21 and Ativan. 2. The facility's medication management plan (revised 11/16/2019) that was in effect at the time of the incident states "Liquid form of medication to be sent back to the pharmacy to be destroyed". Staff # 4 documented on the Medication Destruction form the disposal of 15 mil of Hyosyne on 4/9/2021. 3. The facility's medication management plan in effect at the time of the inspection states" In the event that a medication must be destroyed on site, the License Nurse/Registered Medication Aide shall ensure medication in tablet form will be crushed and poured into sharp's container. Staff # 3 wrote on the Medication Error form dated 4/2/21 "Destruction of 7 medications weren't properly destroyed". Staff # 3 also wrote "She (staff # 1) stated she took a few cards with her to the bathroom while she used the restroom. She had popped out some meds prior to going to the bathroom and disposed of them in the sharps container. She had popped them out from the card in the nursing station. (staff # 2) offered to help her with destroying the meds... While (staff #1) was in the bathroom, (staff # 2) took the remainder of the cards and placed the popped out medications in the sharps container". Staff # 1 in her written state ment identified the medications as as well butrin (tablet), activan (tablet) and senna (tablet), eloquis (tablet), tylenol (tablet) and carafate (tablet).
Plan of Correction:	All medication will be returned to pharmacy for destruction. Documentation will be on file at EH and pharmacy. Staff # 1 and # 2 have been terminated.
Standard #:	22VAC40-73-680-B
Description:	Based on a review of facility documentation and staff interviews, medications were opened and removed from the pharmacy container by a staff person not licensed, registered, or acting as a medication aide on a provisional basis as specified in 22VAC40-73-670. Evidence: 1 Staff # 2 is a personal care aide (PCA).who is not licensed, registered, or acting as a medica tion aide on a provisional basis as specified in 22VAC40-73-670. 2. A Medication Error Report completed by staff # 3 on 4/2/2021 documented "LPN allowed PCA (staff # 2) to destroy several cards of medication without witnessing the act". 3. A written statement from staff # 3 dated 4/7/2021 documented that staff # 2 (PCA) reported". took remainder of cards and placed the popped out medications in sharp's container". 4. Staff # 1 in a written statement dated 4/1/2021 wrote "she (PCA) destroyed some of them to help me out. She said she would use sharp's container while I was in the bathroom".
Plan of Correction:	Staff # 1 and 2 have been terminated. All medication will be returned to pharmacy for destruction. Documentation will be in file. Staff 1 - terminated 4/192021 Staff 2 - terminated 4/3/2021