VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bentley Commons at Lynchburg
1604 Graves Mill Road
Lynchburg, VA 24502
(434) 316-0207

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: April 22, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 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 4/22/2021and concluded on 6/18/2021. A complaint 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 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.

Violations:

Standard #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based on a review of resident medication administration records (MARs) and the facility medication management plan, the facility failed to ensure that medications were reordered in a timely manner to avoid missed doses. EVIDENCE: 1. The April 2021 MAR for resident 1 has a physician order for Refresh Plus 0.5% eye drops, 1 drop into both eyes 3 times a day for dry eyes. The MAR has staff initials that are signed and circled as not administering the medication on 4/13/21 through 4/15/21 and 4/19/21 through 4/22/21. The medication notes page has documentation that the medication was not administered because it was unavailable, not in the cart, family to provide, refill reordered and waiting on pharmacy. 2. The March 2021 MARs for resident 4 has a physician order for Primidone 50mg, half a tablet at bedtime for 1 week on 3/4/21 through 3/10/2021. The MAR has staff initials that are circled as not administering the medication at 9pm on 3/9/21 and 3/10/21 with documentation on the medication notes that the medication refill was pending. The March 2021 MAR also has a physician order for Primidone 50 mg,1 tablet at bedtime for 1 week on 3/11/21 through 3/17/21. Staff initials on the MAR are circled on 3/11/21, 3/12/21 and 3/13/21 as not administering the medication with documentation on the medication notes that unable to locate med, refill pending and waiting on pharmacy.
Plan of Correction:	Executive Director will review current Medication Management Plan and re-write plan to include all required procedures per standards requirements to be within compliance.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on a review of resident records and medication administration records (MARs), the facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions. EVIDENCE: 1. The record for resident 3 has a physician order dated for 8/27/20 for Hydralazine 25mg twice a day for Hypertension, hold for systolic blood pressure less than 100 and a physician order dated 8/28/20 for Benazepril HCL 10mg every morning for hypertension, hold if systolic blood pressure is less than 100. The March 2021 MAR for resident 3 has staff initials that are circles as not administering either medication at 9am on 3/3/21 with documentation that that the medication was held because of outside of parameters but the MAR does not have documentation of the resident blood pressure to determine that the systolic blood pressure was less than 100. The April 2021 MAR for resident 3 has staff initials circled as not administering either medication on 4/6/21, 4/12/21, 4/14/21, 4/17/21 and 4/18/21. Staff documentation indicate that the medication was held on these days because of outside of parameters. Resident 3's blood pressure that was documented for these held doses show that their systolic blood pressure was above 100 and the medications should have been administered.
Plan of Correction:	1. Nurses or Director of Nursing will notify residents? Primary Care Physicians of any changes in orders immediately. PCP outside of facility will be notified immediately on physician order sheet by fax and phone. House physician will be called immediately for notification and will review/sign physician order sheets during next clinical visit. 2. Director of Nursing immediately verbally addressed these issues along with corrective action to all Registered Medication Aides and Nurses on 6/15/21, 6/16/21. Director of Nursing spoke individually with RMA/Nurse of violations and issued medication errors to explain their part in the error and a corrective action. Medication aides were present for Medication Refresher course on 5/18/21 and 5/19/21.Going forward, Director of Nursing will be notified of weight changes and assess need to notify physician. Director of Nursing and/or LPNs will be conducting daily MAR checks.
Standard #:	22VAC40-73-680-I
Complaint related:	Yes
Description:	Based on a review of medications administration records (MARs), the facility failed to ensure that all required information was documented on resident MARs. EVIDENCE: 1. The March and April 2021 MARs for resident 1 do not have start dates for the residents prescribed medications. Also the March and April 2021 MARs for resident 1 do not have documentation of staff initials for the administration of the following medications: Duloxetine 30mg at 8am on 3/6/21 and 3/7/21; Refresh Plus Eye drops at 8pm on 4/16/21, 4/17/21 and 4/18/21 and Tamsulosin HCL 0.4mg at 8pm on 4/2/21, 4/17/21 and 4/18/21. 2. The March and April 2021 MARs for resident 2 do not have documentation of staff initials for the administration of the following prescribed supplement: Ensure Liquid at 9am on 4/14/21 and at 9pm on 3/6/21, 3/7/21 and 3/15/21. 3. The March 2021 MARs for resident 3 do not have documentation of staff initials for the administration of the following medications: Calmoseptine Onitment in the AM on 3/19/21 and the PM on 3/3/21, 3/4/21, 3/6/21 and 3/7/21. 4. The April 2021 MARs for resident 5 do not have staff initials for the administration of the prescribed medication Calcium Citrate 250mg at 8am on 4/5/21.
Plan of Correction:	Director of Nursing immediately verbally addressed these issues along with corrective action to all Registered Medication Aides and Nurses on 6/15/21, 6/16/21. Director of Nursing spoke individually with RMA/Nurse of violations and issued medication errors to explain their part in the error and a corrective action. Medication aides were present for Medication Refresher course on 5/18/21 and 5/19/21.Going forward, Director of Nursing will be notified of weight changes and assess need to notify physician. Director of Nursing and/or LPNs will be conducting daily MAR checks.