VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Stratford House
1111 Main Street
Danville, VA 24541
(434) 799-2266

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: June 30, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A non-mandated complaint inspection was initiated on 6/30/2021 and concluded on 7/2/2021. A complaint was received by the department regarding allegations in the areas of resident care and related services; personnel; and staffing and supervision. 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(s)/self-report) of non-compliance with standards or law, and violations were issued. Any violations not related to the (complaint(s)/self-report) but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on resident record review, the facility failed to administer medication in accordance with the prescriber's instructions. EVIDENCE: 1. The medication administration record (MAR) for resident 2 lacks documentation to support that a lidocaine external patch (5%) was removed at the end of 12 hours. This documentation was missing on May 6, 8, 9, 12, 13, 17, and 18, 2021. 2. The MAR for resident 2 lacks documentation to support that Lubricating Eye Drops Ophthalmic Solution 0.40-0.3% were administered at 3pm on 5/6,16 and 19/2021, at 7pm on 5/14, 16, 16, and 19/2021, and at 11pm on 5/6, 8, 9, 12, 13, 17, and 19/2021.
Plan of Correction:	What was done to correct: The two RMA?s responsible for the errors are no longer employed at the community. How will the recurrence be prevented? All RMA?s received additional training on administering medications in accordance with the physicians? orders on 7/14/21. Random weekly reviews of the Medication Administration Records will be conducted to identify potential medication errors/documentation omissions. Person Responsible: RCD, ARCD or designee
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure documentation on a medication administration record (MAR) was complete. EVIDENCE: 1. The MAR for resident 2 shows that on May 6, 8, 9, and 12 through 19, there is no explanation on the back of them MAR to explain why there is no documentation (initial of RMA) on the front of the MAR to show that a Lidocaine patch was removed, or that eye drops were administered.
Plan of Correction:	What was done to correct: The two RMA?s responsible for the errors are no longer employed at the community. How will the recurrence be prevented? All RMA?s received additional training on administering medications in accordance with the physicians? orders on 7/14/21. Weekly reviews of medication errors will be conducted with additional training given as needed. Person Responsible: RCD, ARCD or designee