VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Elms of Lynchburg
2249 Murrell Road
Lynchburg, VA 24501
(434) 846-3325

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: July 12, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 22VAC40-90 The Criminal History Record Report

Comments:

A focused monitoring inspection was initiated on 07/12/2021 and concluded on 07/12/2021 to follow up on previously cited standards during the facility's recent renewal inspection and a recent complaint inspection. The Administrator was contacted by phone to initiate the inspection. The inspector emailed the Administrator a list of items required to complete the inspection. The LI reviewed staff schedules, current physician orders and medication administration record for one resident, completed criminal record checks for two newly hired staff and initial training for one staff. The evidence gathered during the inspection determined on repeat violation. Any additional violations cited can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-1130-C
Description:	Based on document review and staff interview, the facility failed to ensure during night hours that when 22 or fewer residents are present, at least two direct care staff members shall be awake and on duty at all times in each special care unit and shall be responsible for the care and supervision of the residents. EVDIENCE: 1. Interview with staff 4 revealed that the facility's census for 07/10/2021 was 20. Based on the census, there should have been 2 direct care staff on duty at all times during the night hours on 07/10/2021; 11PM through 7AM. The facility's "Daily Assignment Sheet", used as the facility's schedule, showed that there was only one direct care staff on duty from 3:18AM through 5:00AM. Interview with staff 4 confirmed that this was accurate.
Plan of Correction:	Star system is in place to accommodate call outs. In the event of unforeseen emergencies, management will provide coverage until coverage need is met in end of shift. 2 staff who resides in close proximity will be on call for emergency events/concerns with staffing and need for staff to leave community.
Standard #:	22VAC40-73-650-B
Description:	Based on resident record review, the facility failed to ensure that physicians or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements included the diagnosis, condition, or specific indications for administering each drug. EVIDENCE: 1. The record for resident 1 contained a physician's order, dated 06/30/2021, for "Cefdinir 300 mg po bid x 14 days #28" and a physician's order, dated 06/30/2021, for "prednisone 20 mg tabs #15 po bid x 5 days then po qd x 5 days start 7/4/2021 if not better w/ antibiotics done" The physician's orders did not identify the diagnosis, condition, or specific indication for administering the drug.
Plan of Correction:	DRC/RCC will be sure to review orders for corresponding DX. Correspondence to outside physicians/PCP requesting all medications prescribed be accompanied with diagnosis.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review, the facility failed to ensure that medications were administered in accordance with physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 1 contained a physician's order, dated 05/21/2021, for "Miralax by mouth 1-2 times daily as needed for constipation. First dose of Miralax @ 0700 Second dose of Miralax @ 1900". 2. The July 2021 Medication Administration Record (MAR) for resident 1 showed the medication was administered on the following dates and times: 07/04/2021 at 2:21PM, 07/08/2021 at 1:25PM and 07/12/2021 at 9:21 AM.
Plan of Correction:	New orders will be reviewed by DON/ED and reach out to pharmacy and check EMAR to ensure EMAR order is transcribed as written. Clarification of order obtained - No specific times on PRN orders staff educated on being sure with order transcription. New order monitoring will be conducted weekly.
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, the facility failed to ensure that the medication administration record (MAR) contained all required elements. EVIDENCE: 1. The July 2021 MAR for resident 1 did not contain the diagnosis, condition, or specific indications for administering the following drugs or supplements: Amlodipine 5MG, Azopt drops 1%, Brimonidine drops 0.2%, Sertraline 50MG, Vitamin D2 1,250 mcg.
Plan of Correction:	Consulted with NP and attending physician requested that all medication orders be accompanied with diagnosis. Notification letter to all PCP/NP to include PACE.