VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Carriage Hill Retirement
1203 Roundtree Drive
Bedford, VA 24523
(540) 586-5982

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Aug. 4, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

A non-mandated self-report inspection was initiated on 08/04/2021 and concluded on 08/11/2021. A self-report was received by the department regarding allegations in the areas of staff and resident care and related services regarding medication management. 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 self-report of one standard of non-compliance, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-680-H
Description:	Based on document, resident record review and staff interview, the facility failed to ensure that at the time a medication is administered, the facility documented on a medication administration record (MAR) all medications administered to residents. EVIDENCE: 1. The record for resident 1 contained a physician?s order, dated 04/12/2021, for ?Hydrocodone-Acetamin 10-325MG (Norco 10/325 Tablet) ? Take One Tablet By Mouth At Bedtime As Needed for Pain ? PRN Indicated For Pain?. The ?Controlled Drug Record? for this medication for resident 1 showed that a quantity of 30 of this medication was received by the facility on 07/26/2021 and ?signature of nurse receiving medication? was staff 1. At the time of receipt the medication card contained 30 tablets labeled 1 through 30 and contained one tablet per blister. The ?Controlled Drug Record? for this medication for resident 1 contained staff 1?s signature that she had removed tablet 30 on 07/26/2021 at 9:00PM and tablet 29 at 7:00PM and tablet 28 at a time that was not legible on 07/27/2021. Picture evidence of the medication card provided to the licensing inspector (LI) by staff 2 on 08/04/2021 of this medication for resident 1 showed that tablets 30, 29, and 28 were missing from the card. See (ALF1104146 07-28-21 P1) attached. The July 2021 MAR for resident 1 showed during the time period of 07/26-27/2021 that this medication was administered only on 07/27/2021 at 8:14PM by staff 1. There was no documentation on the MAR that the medication was administered on two other occasions by staff 1 during this time period. 2. The record for resident 2 contained a physician?s order, dated 07/23/2021, for ?Oxycodone 5mg tab ? tab (2.5mg) PO q 4 hrs. PRN breakthrough pain. #30 (thirty).? The ?Controlled Drug Record? for this medication for resident 2 showed that ?No. of Doses Received: 60? of this medication was received by the facility on 07/24/2021 and ?signature of nurse receiving medication? was staff 1. At the time of receipt the medication card contained 60 tablets labeled 1 through 60 and contained half a tablet per blister. The ?Controlled Drug Record? for this medication for resident 2 contained staff 1?s signature that she had removed tablet 60 on 07/26/2021 at 7:00PM, tablet 59 on 07/27/2021 at 12:00AM, tablet 58 on 07/27/2021 at a time that was not legible, tablet 57 on 07/27/2021 at 7:00AM, tablet 56 on 07/27/2021 at 7:00PM and tablet 55 on 07/27/2021; however, there was no time documented of when staff 1 removed tablet 55. On 07/28/2021 tablets 54 and 53 were removed by staff 1 but there was no time indicated when these two tablets were removed. Picture evidence of the medication card provided to the LI by staff 2 on 08/04/2021 of this medication for resident 2 showed that tablets 60 through 53 were missing from the medication card. See (ALF1104146 07-28-2021 P2) attached. The July 2021 MAR for resident 2 showed during the time period of 07/26/2021 through 07/28/2021 showed this medication was only administered to resident 2 on 07/27/2021 at 7:48PM and 07/28/2021 at 12:42AM by staff 1. There was no documentation on the MAR that the medication was administered on the six other occasions by staff 1 during this time period. 3. The record for resident 3 contained a physician?s order, dated 07/23/2021, for ?Tramadol 50 mg PO TID PRN Pain #90 (ninety).? The ?Controlled Drug Record? for this medication for resident 3 showed that a quantity of 90 tablets of this medication was received by the facility on 07/23/2021. Interview with staff 4 confirmed this was accurate. The ?Controlled Drug Record? for this medication for resident 3 contained staff 1?s signature that she had removed tablet 30 on 07/23/2021 at a time that was not legible, tablet 29 on 07/24/2021 at 7:00PM, tablet 28 on 07/25/2021 at 5:00AM, tablet 27 on 07/25/2021 at 7:00PM, tablet 26 on 07/25/2021 at 8:00AM
Plan of Correction:	Please see Intensive Plan of Correction