VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cardinal Senior Communities
1350 Longwood Avenue
Bedford, VA 24523
(540) 586-0825

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Sept. 23, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION.

Comments:

A non-mandated complaint inspection was initiated on 09/23/2021 and concluded on 10/20/2021. A complaint was received by the department regarding allegations in the areas of personnel, admission, retention and discharge of residents and resident care and related services. 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 did not support the allegations of non-compliance with standards or law. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-710-F
Complaint related:	No
Description:	Based on resident record review and video evidence the facility failed to ensure that when restraints are used in emergencies, as defined in 22VAC40-73-10, an oral or written order was obtained from a physician within one hour of administration of the emergency restraint and documented. EVIDENCE: 1. ?Cardinal Senior Living Resident Notes? by staff 1, dated 08/05/2021, stated ?Resident yelling in the hallway and physically aggressive ? unable to redirect ? staff attempted to work with resident to calm him down ? all attempts unsuccessful ? 911 called ? (Collateral 1) arrived at facility ? stated they would not take him to ER to call POA to take him ? POA- arrived @ facility ? resident left with POA to go to (hospital) for evaluation and treatment as indicated?. 2. Video evidence provided by Collateral 1, dated 08/05/2021, showed resident 1 sitting in a chair in the facility?s lobby at the entrance of the building. From at least 7:03AM until 7:04:29AM Staff 2 was standing on the right side of the resident with her right arm underneath the resident?s right arm and staff 3 was standing on the left side of the resident with her right arm underneath the resident?s left arm holding the resident down in the chair. 3. The oral physician?s order, dated 08/05/2021, provided by staff 1 and 4 did not contain documentation that the oral physician?s order had been obtained from the physician within one hour of administration of the emergency restraint.
Plan of Correction:	I. The facility has documentation of the order that was obtained from the physician prior to administration of the emergency restraint. II. The administrator and/or designee will ensure all orders are time stamped when needed for the use of emergency restraints. III. The administrator will review all incident reports related to the use of emergency restraints ongoing and sign off on the incident report acknowledging all requirements are being met IV. Date of completion: November 1st, 2021