VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sunrise at Hunter Mill
2863 Hunter Mill Road
Oakton, VA 22124
(703) 255-1006

Current Inspector: Alexandra Roberts

Inspection Date: Aug. 10, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

A non-mandated complaint inspection was initiated on 8/10/21 and concluded on 10/6/21. A complaint was received by the department regarding allegations in the areas of: Admission, Retention, and Discharge of Residents, Resident Care and Related Services, and Building and Grounds. The administrator was contacted by telephone to conduct the investigation. The licensing inspector conducted an on-site observation at the facility on 8/10/21. The evidence gathered during the investigation supported the allegation 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 #:	22VAC40-73-325-C
Complaint related:	Yes
Description:	Based on documentation and interview, the facility failed to document an analysis of the circumstances of falls and interventions that were initiated to prevent or reduce risk of subsequent falls. Evidence: The record for Resident #1, admitted 4/22/21, was observed during the inspection. Resident #1's Uniform Assessment Instrument (UAI), dated 4/22/21, states that the resident needs mechanical and physical assistance for walking and mobility. Resident notes indicate that Resident #1 fell on 4/22/21 (4:15 PM), 4/27/21 (4:15 AM and 11:00 AM), and 4/28/21 (1:10 AM, 6:00 AM, and 9:15 AM). Some progress notes reported that Resident #1 was agitated and anxious after falling, and PRN medication was given as a result. No information was found in the record to document an analysis of the circumstances of the falls and interventions that were initiated to prevent or reduce risk of subsequent falls. Facility staff confirmed that no additional information was present, to document the required information.
Plan of Correction:	Resident #1 passed away at the hospital. A review of residents that the UAI indicates the need of mechanical assistance for walking and mobility was completed to verify the ISP is up to date and interventions have been documented. Any issues identified were addressed. Recent fall events were reviewed to verify a root cause analysis was conducted and documented in the resident's record. The resident ISPs were reviewed to verify interventions have been updated. Any issues identified were addressed. The Executive Director provided education to the Wellness Department and the Care Coordinators on the use of the UAI to develop interventions based on resident needs. The ED also reviewed conducting a root cause analysis when a fall event occurs and updating an ISP based on resident needs. Upon move-in, change of condition, semi-annually and annually the resident is evaluated and UAI completed along with an ISP, which includes interventions based on the residents needs. Upon a fall event, the event is evaluated to determine the root causes and the resident record is updated with a revised ISP intervention. The ED or designee verified the ISP is updated in the resident record. The POC is evaluated by the ED and coordinators at the monthly Quality Assurance and Performance Improvement (QAPI/Quality Management) meeting for 3 months to ensure it is still effective. If it is no longer effective, it will be amended and a new POC will be implemented and monitored to ensure the violation does not occur again. The Executive Director or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.