VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Chesapeake Place
1500 & 1508 Volvo Parkway
Chesapeake, VA 23320
(757) 548-0808

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: July 1, 2021 , July 8, 2021 , July 19, 2021 , July 23, 2021 and July 30, 2021

Complaint Related: Yes

Areas Reviewed:

Resident Care and Related Services Staffing and Supervision Buildings and Grounds

Comments:

A non-mandated complaint inspection was initiated on 07-01-2021 and concluded on 07-30-2021. A complaint was received by the department regarding allegations in the areas of Resident Care and Related Services, Staffing and Supervision, and Buildings and Grounds. 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 licensing inspector conducted an on-site observation at the facility on 07-02-2021. The evidence gathered during the investigation supported the allegations 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 #:	22VAC40-73-460-E
Complaint related:	No
Description:	Based on record review and interview, the facility failed to regularly observe and document in the resident?s record any changes in the resident?s condition to include injury, and any corresponding action taken. 1. Resident #1?s May 2021 Medication Administration Record (MAR) documented the resident received Hydroco/Apap 5-325mg for pain on 05-19-2021 and 05-20-2021. The MAR also documented the resident was sent out to the hospital on 05-23-2021. 2. During interview, staff #1 stated the resident was sent out to the hospital due to ?complaints of back pain.? 3. Resident #1?s skilled nursing facility (SNF) ?History of Physical? form dated 06-01-2021 documented the resident was transferred to the SNF from the hospital after being admitted there for lumbar back pain. The resident was found to have an L3 compression fracture of the spine. 4. Staff #1 could not provide documentation regarding the resident?s complaints of back pain or the reason why the resident was sent out to the hospital.
Plan of Correction:	RCD and ED will insure that proper documentation is done when resident is admitted to SNF. Systems will list resident as on a "Leave of Absence." Upon readmission, new orders will be immediately send to pharmacy and RCD will verify new orders in system and medications upon delivery.
Standard #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to implement their medication management plan to include, methods to ensure that each resident's prescription medications ordered for the resident are filled in a timely manner to avoid missed dosages. Evidence: 1. Resident #1 admitted to the facility on 05-12-2021 (admission date confirmed by staff #1). 2. Staff #1 provided a copy of the facility?s ?Medication Refills? policy dated 12-01-2020, which documented ?Medication refills will be obtained in a timely manner to ensure residents have all physician ordered medication available.? Staff #1 could not provide a copy of the facility?s policy regarding filling new medications. 3. Resident #1?s physician?s orders dated 05-06-2021 documented, ?Calcium 600mg daily; Lasix 20mg daily; Metoprolol 25mg BID [twice a day]; Sodium Chloride 1gm TID [Three times daily]; and Valsartan 160/25mg daily. 4. Resident #1?s May 2021 Medication Administration Record (MAR) did not document staff administered the aforementioned medications on 05-13-2021 through 05-22-2021. The MAR documented the aforementioned medications were not administered due to ?Med on order? Clarifying HOA- Waiting on MD Response?? 5. During interview, staff #2 stated she spoke with staff and could not confirm the aforementioned medications were administered; nor could staff #2 not provide documentation that the aforementioned medications were administered to resident #1 on 05-13-2021 through 05-22-2021. 6. Staff #2 could not provide documentation confirming the pharmacy delivered resident # 1?s aforementioned medications to the facility at the time of admission; and acknowledged the aforementioned medications were not filled in a timely manner to avoid missed dosages.
Plan of Correction:	RCD, ED, and pharmacy conducted full audit to ensure that all resident's medications were in system after previous RCD deleted records. ED will ensure that any terminated employees access to QMar and AL Advantage at immediately deactivated. Cart audits are routinely conducted to ensure that alerts are set so medication can only be administered as directed by physician order.
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on record review and interview, the facility failed to administer medications in accordance with the physician's instructions. Evidence: 1. Resident #1?s signed physician?s order dated 05-17-2021 documented ?Cephalexin 500mg PO Q12 hours x 5 days.? 2. Resident #1?s June 2021 Medication Administration Record (MAR) documented staff administered the first does of Cephalexin 500mg on 05-19-2021 at 9:00 PM and the last dose was administered on 05-23-2021 at 9:00 AM. The resident did not receive the Cephalexin 500mg for 5 days as ordered by the physician. 3. Resident #3?s current signed physician?s order dated 06-23-2021 (original order dated 04-17-2019) documented ?Methotrexate Tab 2.5mg- 4=10mg by mouth once a week on Friday.? 4. Resident #3?s June 2021 MAR documented staff administered Methotrexate 2.5mg Wednesday, 06-02-2021 and Thursday, 06-03-2021. 5. Staff #2 did not provide a physician?s order for Methotrexate 2.5mg to be administered daily, and acknowledged resident #3?s Methotrexate 2.5mg was not administered once a week as ordered by the physician.
Plan of Correction:	RCD and ED will insure that proper documentation is done when resident is admitted to SNF. Systems will list resident as on a "Leave of Absence." Upon readmission, new orders will be immediately sent to pharmacy and RCD will verify new orders in system and medications upon delivery.
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on record review and interview, the facility failed to ensure the Medication Administration Record (MAR) included the initials of direct care staff administering the medications. Evidence: 1. Resident #2?s May 2021 MAR did not include the initials of direct care staff administering the following scheduled medications: A. 8:00 AM Metoprolol 25mg on 05-21-2021; B. 9:00 AM Atorvastatin 20mg on 05-19-2021, 05-21-2021, and 05-24-2021; Eliquis 2.5mg on 05-14-2021, 05-22-2021, 05-23-2021, and 05-27-2021; Furosemide 20mg on 05-16-2021, and 05-18-2021 through 05-25-2021; C. 2:00 PM Tramadol 50mg on 05-06-2021, 05-12-2021, 05-13-2021, 05-19-2021, and 05-23-2021; D. 5:00 PM Eliquis on 05-17-2021 and 05-23-2021; and E. 9:00 PM Furosemide 20mg on 05-17-2021, 05-21-2021, and 05-22-2021. 2. Staff #2 acknowledged the aforementioned dates did not include the initials of the direct care staff administering the medications.
Plan of Correction:	RCD, ED, and pharmacy conducted full audit to ensure that all resident's medications were in system after previous RCD deleted records. ED will ensure that any terminated employees access to Qmar and AL Advantage are immediately deactivated. Cart audits are routinely conducted to ensure that alerts are set to medication can only be administered as directed by physician order.