VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Staunton
1900 Hillsmere Lane
Staunton, VA 24401
(540) 885-9500

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: Sept. 1, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Ensure medication management plan reflects procedures as it relates to preventing use of discontinued medications.

Comments:

A non-mandated self-report inspection was initiated on 09/01/2021 and concluded on 09/03/2021. A self-reported incident was received by the department regarding allegations relating to medication administration. 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 non-compliance with standards or law, 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 #:	22VAC40-73-450-E
Description:	Based on review of resident's record, the facility failed to ensure the Individualized Service Plan is signed and dated by the administrator, or his designee and by the resident or his legal representative. EVIDENCE: 1)The ISP dated 06/28/2021 for resident 1 does not contain a signature and date of the administrator, the person who developed the plan, the resident or his legal representative.
Plan of Correction:	Resident 1 ISP has been reviewed and the required signatures were obtained from Executive Director, HWD or designee and legal representative no later than 9/21/2021. Current ISP emailed to legal representative and a copy of email was attached to the ISP until signature obtained from the legal representative. Re-training for staff certified to complete ISPs and UAIs was conducted by the Health and Wellness Director (HWD)/designee on 9/10/2021. Retraining consisted of assessments competency for the ISPs and the UAIs, requirements for signatures, and communication of all ISP to residents or legal representatives. The HWD/designee will conduct an audit of current residents ISP?s and UAI?s no later than September 30, 2021, to verify the ISPs and UAIs are completed with signatures. To assist with ongoing compliance, the ISPs and UAIs will be reviewed on a random basis on a weekly basis for four (4) weeks and then on a monthly basis thereafter for six (6) months by the HWD/designee.
Standard #:	22VAC40-73-680-D
Description:	Based on document review, the facility failed to ensure medications are administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum. EVIDENCE: 1. Resident 1 has an order to discontinue Humulin sliding scale insulin effective 08/17/2021. 2. The facility incident report submitted on 09/01/2021, indicates resident 1 was administered 25 units of Humulin on 08/31/2021 at 2:30pm. The incident report indicates "it was brought to the nurse's attention, by the resident's family member, that he had received 25 units at 2:30pm today."
Plan of Correction:	1). Resident 1 Insulin orders were clarified reviewed and residents blood sugars were monitored through the night for adverse effects. No adverse effects were noted for Resident 1. Systemic Changes 1). The Health and Wellness Coordinator conducted an in service on Medication administration and reviewed the standards of Practice form outlined in the current registered medication aid curriculum approved by the Virginia Board of Nursing on 9/1-9/3/2021 for Medication aids and Licensed nursing staff. 2). Medication Aid for Resident 1 received a 1:1 education and counseling for medication error on 9/1/2021 and the individual Medication Aid completed additional education for medication administration by 9/10/21. Monitoring 1).To assist with ongoing compliance, the Health and Wellness Director, Health and Wellness Coordinator or designee will review Daily progress notes and PRN documentation to verify medication administration.